05040015 (2) ° CITY OF CUPERTINO 717.7',47,
BUILDING DIVISION PERMIT
auILDiNG ADDRESS: JEFFREY MILLER, GENERAL CO Tr"05040015
0100 PT4AR T.AP MR
OWNER'S NAME: PERMIT ISSUE DATE
CAR
ONE: SANITARY O. 0 OL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
l�
o o LICENSED CONTRACTOR'S DECLARATION
dl 1 Wrtum Nwed
by strum I are roosted under pmvWons of Chapter 9(commencing Job Description
In full
uSmrce 7l101I)o(DlWion 3 o(NC Butincuand Pmfcssinu CoM.and my license a
License
Class erceck REPLACE WATER HEATER
�z Lxcnse Ciw 1x.11
Dau ConlrscWr
As shall W use DECLARATION Ok
I understand my plain shall he used at public records 401;
ills
Licensed fcsdonH
OWNER.BUILDER DECLARATION
iI 1 hereby aObm that 1 em exempt from the Contractor's License Lew for the �.t�
S 0 following eemen.($moon 7n319,Business and Professions Cade:My city or county V
which requires a Permit to construct.41mr,hnprow,demolish,or repair my uncture
plot to its issuance.Alan requires the applicant farsuch Permit On rile a signed summcm
< thalheuRcewdpurwantmNepmvision"fftCm=wf+UcewLaw(ChapW9 Sq.Ft.Floor Area Valuation
(commemingwith Smdon7o0)of Divisim3ofthe Buinwmd Profwimu Ca )or
9 But he Is exempt Nert(rom and the basis for the alleged exemption.My violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penally of 3 2WA18`fl*Lbgr0 0 Occupancy Type
not more Nan rtes hundred dollars(5500).
❑I.0 owner of the pmpoty,mmY moplayes with wagau Neirmle cotnpewtiu,
alit Pr Newark,Cde:The cwtobim's Lided mawdo fm sat apply to an Owner
Required Inspections
mtl PmfeWmu Code:The Conuecmr's Llttw Law duo not apply rf an owner of q p
property whobutIdavied t aws Merton,and who does such wok himselfer through bit
wn
oemployes,provided that each ImPmsemmu art not intendedofc moaered for the O e.r..
Wilder Ne Wilding orimpwwmentisust within one year of completion,the owner.
Wilder will haw W burden of proving Nal he did cot Wild or Improve for purpose of
tile.).
O 1,as owner of the property.am exclusively contracting with licensed conuasom to
constmcl the Aect(Sec.70A,Business and Pro(wion$Code:)The Conlrtcur',LI-
On Law mlapply Nanowrcrof pmppny who Wild+or improve therton,and,
whocor u rmch ptnjeeu with aon"
IixwdpurTanlwde Con s
Lken w 71
❑i ax to r c PCf u
Game
WORKFE' OMPENSATION DECLARATION
I hemby a(I' under peulty a(perjury one of tic following deal one:
1 haw and will maintain a Certificate accosted to self-insum for WmIsn'sCampen-
sstlan,u provided far by Section 3700 of the Labor Cade,for the per(omance of the
wok for which this permit u issued.
❑1 have and will maintain Worker's Compewoan Insurance,u requlmd by Section
3700 of the Labor Coda,for the performance of the work for which this permit is Issued.
My Workers Compensation I"mnme artier and Policy number are:
Canis Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(Th ectiannod otbecompleNd if Uc pe his fa one on Mllw(SIns)
or ksa)
Ito
I.the pm(omtantt Om work fm cl n omit' isau .1 WII nit
mnpl pe on inanY nn tub oma act h Ya en' n pe Bon
Law u i a
Appl
NOTICE T6—AP?LicANr. t.argirmaking this cenificaw
become subject 0 NWorker's Compensation provluonsof of Ea yn
m
.J O forthwith comply with such provisions or Nis permit hall be domed ked.
z` CONSTRUCTION LENDING AGENCY
'tom+ IhetobY am.CONSTRUCTION
thoto is a oourlctin"lending agency far due performance of
ai> the work for which this permit it issued(So.3097,Civ,C.)
0.Q Loder's Name
.7. z Lenders Address
U Q I certify that I have rad this application and sum that the Above information Is
U.F Comm I agtoe to comply with W city and county oNlnuceand store law,totaling to
OU Wildingcon oon,andhere ym olm repreanutisesofNuciy wenter upon the
W abuw-men' red ptopeny(m lupco on purposes
agree to rave,led cmni(y and tree harmless the City of Cupertino against
CAIiab ,Judgmemtawa
a,cmandexpewsw i y l"my y seem agabutding of th .uld City
U^" 1 Po 1 ANT UNDER of MANos AND FLY I ALL NON- Issued by: Date
S REGULATI s
e-roofs
nga areof Iiacar u
HAZARDOUS Ror. MATERIALS DISCLOSURE Type of Roof w
WIII the applicant o applicant fmure Wilding mcupant stow or Mrblc harallou+mawdu
u Mnncd by the CupeNno Municipal Code.Chapter 9.12.and the Health and Safely
Idm'
k.Sermon us3z(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya QNo
Will the applicant or future building occupant that equipment or devices which If a roof'tis installed without first obtaining an inspection,I agree to remove
it hrrardous air contaminants u donned by the Bay Area Air Quality Matugcment all new materials for inspection.
mict7
Oyu [I No
h mad NehuardammauriaHmyui Uhnde'Chapter6.95ofNeCalifor-
,I Safely CAM,Sotrans25505,3l5J SJe.lundcntandthulfthe Wildin
n urtently haw a ten I.Nu it b in ity m nod( the meupant f
w i tu" ' 'w Signature of Applicant Date
owner car mnalmd.genl w All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
aClOF
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPEkTINO
Building Department
JOBD SS: n Q� S PERMIT
! qac C,��9
OWNER'S NAME: / LL �� PHONE # 7-6;, a5-2)GENERAL CONTRALTO _ /L AX# 7— / (o
I am not using any subcontractors:
Signature . Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
er/Contractor Signature Date
CITY OF CUPERTINO
WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN# s.� ', i Date:
Buildino�flllr-a s0 �
Own s /�70 L 1 / ' IVI LLL P �57- GLS
� Phone:
Contact`: / ` wC Phone: Cupertino BusinessLicense#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: 7� J
Residential (tet/ Commercial ❑
Cost of Projects45z)
• Strapped On Platform Bonded
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING