03120072 (2) .5 CITY OF CUPERTINO
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BUILDING DIVISION - PERMIT ' Cd �YL\i' ATQLN vac,?
BUILDING ADDRESS: PMJvUTNO.
HOT WATER INC 03120072
a OWNER'S NAME: - PERMR LSSUE DATE
NE: SANITARY OL NO.
ARCHITECIENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a�oo LICENSED CONTRACTOR'S DECLARATION Job Description
Itit mliaised 1 Wrchy arm drat I am under provisions of Chaps 9(commencing P
n� with Section 7000)of Division 3 of the Burin and Rmfosvuu Cad",and my license is f
in full fano an 1jl
3'qz Lleemetcliaa( �ue.« REPLACE WATER HEATER y -
_ RCHITECrS DECLAR ION �'��Ly`��D
I dcmp d my ptenss all be used u public"curds ��A"'111 iiE
30 `" "—I 'F"T)"FIS C"°�'" ' DEC 3 0 2003
5 OWNER-BUILDER DECLARATION
I hcnby affirm that I am exempt form the Common's License Law for lbe
p O fallowing mason.(Section 7031.5,Business and Pmfeasiuu Code:Any city or county
s'$ which.cut.,a Permit.ctnstroc4 sber,improve.demolish,or.pair any auuctu. §
Our m I%issuance,situ".I.s the applicant for such pcmr iva file.signed settlement p
FFm�m< that he is licensed pursuant to the provisions of the Commutes License Law(Chapter 9 Sq.Ft. Floor Area [io
gFp
(comm encingwith Section70D0)of0iv on3ad.Businessmd Profosiom Code)ur
$ that wens mumps therefrom and the buss far the alleged exemption.Any violatfon of t
Section 7031.5 by any applicant for a permit ubjects the applicant m a civil penalty of 3 I, i}Iy�erp p Occupancy Type
not mo.than five hundred dollars(5500).
❑1,uownuofthapmpeny,mmyemploymwithwgesuthehmlecomM=rim,
will do the work and theswcore Ismotimmoded ort0ened foraalt(Sa.705x,Buinaaa Required Inspections
and Pmfesdom Code:The L'rnlrsemr's Ll.ue law does not apply m an owner of q P
property who Wilds or improves thermn,and whodocumchwark himselfor0uough his
ownemployces,provided thatsuch Improvements are not intended oroRered forule.If,
however,the building or Improvement is mid within one Soar of completion,the owner.
Wilder will have the human of proving that M did not Wild or Improve for purpose of
salt.).
❑L as owner of the property,am exclusively convecting with licensed contractor to
convect the project(Sec.70",Business and Professions Code:)The Commutes LI•
cense law dors not apply in an ower of property who Wilds or improves thereon.and,
who convects for such projects with acomrseror(O licensed pursuant in the Coma owe.
License law. _
0 1 am exempt under Sec. .B At P C for this reason '
i.
Owner Date
WORKER'S COMPENSATION DECLARATION i
1 kmby affirm under penalty of perjury one of the following dalamem:
I have and will mainuin a CeW ficau of Cement to telf-insure for Worker's Com am- l
7C371�'00
un.as provided for by Section 3700 of the Ulm,Cade,for the performer.of the
rk for which this Permit is issued.
1 have and will maintain Worker:Compensation?mum=,as required by Section
of the Lalmr Code,for the Performance of the work far which this Permit is issued. {
y WarkeYs Cempe /1on Insurance cart:.and Poli,nmber jS ���rrier: ( /TTE&WAA ON
O
CERTIFCA— TE�Pr1I NFROM W00.KERs'
COMPENSATION INSURANCE
Gbis mcdon reed not M camplaed If the ptrnR Is for one hundred dollars(S 100)
m less.)
I unify that in the performance of ted work per which this Permit is issued,I shall not i
employ any permn in any mantrm as m bccomc subject to ted Workaf'Compensation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT.IL after making this Certificate of Exemption.you should
become subject"the Worker's conn er sstion provisions of one Labor Code.you mot
.,O forthwith comply with such previsions or this permil shelled deemed mwkcd.
?"' CONSTRUCTION LENDING AGENCY
Fr iN+ I henhy amen that the.is a construction lending agency for the Performance of
tYi 7 the work for which this permit is issued(Sec.3097,Civ.C.) +
Qlender.Name
z Lcudeh Address
U Q I unify Nal 1 have Mad this application and shote that the above Information is
Centel.I agree to comply with all city and County ordinances and sole laws misting to
�U building convection,and hereby authrim mpnsentstives of this city to cn.r upon led
above-mentiomed property for impaction purposes.
. (We)agree to save.indemnify and keep harmless the City of Cuperlinn against
yv0 liabilitim,judgmenu,costs and expenses which may In anyway acme againat asid City
U Z in consequence ofthe gaming of this Permit. /
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE R ,,LdA�(�/jF',.{�DNS. .,,�.,
atgnat PbCm17 aaftr0r I kife`qtrek V Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will ft applicant or future Wilding occupant sate or handle hamclous noormit
u deftrcd by the Cupertino Municipal Cade,Chapter 9.11.and the Health and Safety
Ca dm,Section25531(Q1 All roofs shall be inspected prior to any roofing material being installed.
❑Yes Nu
Will the applicant Wilding occupom vu equipment ardevices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air contaminants a defined by the Bay Arca Air Quality Management all new materials for inspection.
Dimrics9
❑Yes j❑NoNo - ^
I haw mad the hms mud sms¢rolsnqui"menu under Chapter6.95 tithe Califs,
nix Health&SafctyCode.Scew.25505.15533 and 2553x.1 understand ties lithe Wilding
does net cunenrly haw a reel.then it u my responsibility to nudfy de aaup.(of f
requirements which mum W met prior m issuance oft Cenifiow ooffQ pm,. Signature of Applicant Date
��4�
own�;;-7ZTr9_-m Dow All roof coverings to be Class "B"or better
r,
CITY OF CUPERTINO
WATER HEATER 3 Z"
:! CUPERTINO PERMIT APPLICATION FORM
APN# 3&CI 13
030 Date:
Building Address: �
D 5 a o Pr n e ✓�/lam Ove. rf�6) CA 9,�bi�
Owner's Name: Phone #:
"Joh n D e-,DnnDk— o 0?53 - 6g5y
Contractor: hone: icense#:
c 2r &• D &,;3/ A 9
Contact: hone: Cupertino Business License#:
Building Permit Info:
Bldg El Elect ElPlumb P] Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project:
0
• Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replacement
,Qty. if
A l able Fee ID Fee Description Fee Group
BPWHEA TER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
�6s' 6 �