04020055 (2) CITY OF CUPERTINO
BUILDING - PERMIT.:
Bu
M ,rt . ,. �• ., ..;
BUILDING ADDRESS: WATER HEATERS ONLY PERMITND04020055
P TAP DR
OWNER'S NAME: , PERMIT ISSUE DATE
PHYLLIS
'NE: SANITARY 0. CONTROL NO.
ARCHITECf2NGINEER: BUILDING PERMTTINFO
BLDG ELECT PLUMB MECH
up0 LICENSED CONTRACTOR'S DECLARATION
¢F I hereby affirm Out 1 am limiucd under provisions of Chapter 9(commencing Job Description
.n¢4G with Section 7TOB of Division 3 of she Business and Professions Cods.and my become is C w
< infullro and ej� 3--_� REPLACE WATER HEATER FINAL.lE®
j Z Lkenu class La p
Dam C mracmf'
C Y 'f
1
1 undcrsunJ my pan memrdv FEB a 2004
7yu
o Licensed Professional
OWNER-BUILDER DECLARATION BUILDING
I hereby moo amens Net 1 a.1. exempt from the Conons Cm s:Any c Lew for the
x O G following«ssoa.(Smoot 7(171.5,Business,aand improve,
demos Cole:Any city or county
K$ which mquims•Permit totinYmet,alcor,improsuhPermitt care a sig anytatement
Fila^ prior to its issuance,also mquims the applicem for such Permit to filcasigncJ rtetemcm
< that be is licensed pursuant to the previsions of the Contractor's UccouLaw(Chapter 9 Sq.Ft.Floor Area Valuation
F❑$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
3 that he is exempt therefrom and Ne basis for the alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 2"" er0 0 Occupancy Type
not mom than five hundred dollar(SSW).
❑I,as owner of the properly,m my employees with wages as their sole compensation,
will dm the work and theatruclue,is not intended or offered forsale(Sm.IBM,Business
and Professions Code:The Contractors License Law dean not apply to an owner of Required Inspections
properly w ho brei Ids or improves former and who does s uch work himself or through his
own employees,provided that such improvements are not intended oro@red forsale.if,
however.the building or improvement is sold within one your of completion.the owner.
builder will hive the burden of proving that he did not build or improve for purpose of
sale.).
❑1.as owner of the property,am exclusively contracting with licensed contractors to
mnatract the pmject(Ser.7044,Business and Professions Cade:)The Contracmrt Lb
ernes Law does not apply to an owner of property who builds or improves thereon.and,
who contracts for such projects with a contracmrbi)Hemod pursuant to the Contractors .
License Law.
❑I am exempt under See. ,B&PC for this mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affrm under penalty of perjury one of the following declarations:
1 have and will maintain is Certificate of Consent to mlf-insure for Workers Compere
nation,u provided for by Section 37M of the Labor Cade,for the performance of the
rk for which this permit is issued.
I haw and will maintain Workces Compensation Insurance,as required by Section
3700 of the Labor Code.for the performance of Use work her which this permit Is Issued.
My Workers Ccompen50�and nom carrier and Policy number are:
Curtiss: ✓• ? Policy No.: 1485 4 L3
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tho auction need net he completed lithe permit is foreac hundred dollars(51M)
or Ices.)
I certify that in the performance of the work for which Of.permit o broad.l shell net
employ any person in any manner an as in became subject to the Workers'Compensstion
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Ccntftcate,of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.,O forthwith comply with such prevision or this Permit shall be deemed new lacd.
z"" CONSTRUCTION LENDING AGENCY
ice+ T hereby affloni there is a construction lending agency for the performance of
a> the.,it for which this permit is issued(Sec.3097,Co.C.)
6iQ Lender's Name
z Lender's Address
U 0 1 certify that I have mad this application and state that the above information is
IL E correct.I agree to comply with all city and county eminences and seek laws minting to
C)5V^ building consWclion,and hereby outhorim representatives of this city to enter upon the
W above-mentioned property for inspection purpose&
L1a (We)agree in Save,indemnify and keep harmless ftc City of Cupertino against
IA liabilities,judgmcnta,costs and cxporms which may in any way accmn against mid City
t.)'Z in conxegoence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCERE LATIONS.� ?[[_ 4)
Re-roofs
Signe rut Oete
HAZARD S MATERIALS DISCLOSURE Type of Roof
Will the applicant or m,(mum building occupant.Chaptentre or handle Health and
M defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
,idKinde,Section 25372(a)? All roofs shall be inspected prior to any roofing material being installed.
Yea
❑Nu
Will the applicant or(mum building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
CYcs ❑No
1 have mail the hasaNnus materials requirements under Chapter 6.95 of the Califor-
niaHealth&SafelyCoda,Suctions 25505.25533 and 25534.1 understand thatifthc building
does not You
hast a smart.Out it is my responsibility to notify the occupant of fm
nexImomenuw 'ch must be met pd tooance aCenlfese.f Ocmp ry./ Signature of Applicant Date
owns tram All roof coverings to be Class"B"or better
- CITY OF CUPERTINO
WATER HEATER
CUPEI�TINO PERMIT APPLICATION FORM
APN# 3 2 / 3 ( e �� Date:
Building Address: ^ I I O
/oz6 / L ,
Owner's Name: Phone#:
Contractor � O License#: 3 tcS 3
7
Contact: Phone#:
Applicant/CoR4aeter: 7 6� ,> ,5,11_123
�D d r 5 S��/
,> 5,11_/23 Z
Building Permit Info:
Bldg Elect lumb Mech
Job Descri tion:
esidentia) �fr� Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation: 00
Type of Construction: Occupancy Group:
Qty. if
A licable Fee ID Fee Description Fee Group
/ BENERGY Energy BUILDING
BPWHEATER Water Heater/Vent BUILDING
/ PPERMITFEE Plumbing Permit Issuance PLUMBING
BPERMFEE
Bldg Permit Fees BUILIDNG
BMITIGAT Housing Mitigation Fee BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG