05020171 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT 9CONTRAGTOR14i' RMATIQI
+nu£� ;.,�v
au1LDING ADDRESS: WATER HEATERS ONLY PF "'bS020171
272 PTMMTA( T7. PV
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO, CONTROL NO.
(800) 835-5946 BUILDING PERMIT INFO
BLDG ELECTO l� rLUM
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a�er0 Zp LICENSED CONTRACTOR'S DECLARATION Job Descriptio
1 hereby )of that L am fthe Bu under provisions of Chapter 9(commencing
mdsection hereby l)of that elideedunderpr Pro(essiof hak,antico Imenx4
'^ in full fora and eOr�
$$qz Lice..Class Lk.x "J'14
5 7 REPLACE WATER HEATER
L-- Date Ca^uanar
,?eQ As"Ihe need
DECLARATION '
I 1 1 andcreunJ TRY Plans alai's he used u public records
Lkemed Professional
OWNER-BUILDER DECLARATION
f I hereby am.that I am exempt from the Conuactoh License law for the
B so
fallowing man.(Section 703 1.5,Business and Professions Code:Any city or money
which requires a Permit to move val alter.Improve.demol'uh.re repair Any structure
i- Sq prior w iuissuanee.aim requires ft applicant farmch Permit to file signed statement
FF�< that he is licensed pursuant to Use provisions of the Conmoner's Licence Law(Chapter 9 Sq.Ft. Floor Area Valuation
tl (commencing with Section 7(X0)of Division 3 of the Business and professions Cade)at
that he In attempt therefrom and the buts for the alleged exemption.Any violation of
section 7031.note five huMappldolWso5 permit
e it subjects the applicant he a civil penalty of 3 6�D19u2&eID 0 Occupancy Type
met M.
❑I,uawnerorthe property,ssmywployw with wgesutiskank emmpenation.
willdothework,mdthesuvetumismtimmndedwaffemdthuale(Sea.]044,Bu ten Required Inspections
and ProfeAnlov mn Code:The Comracter',Lime law donot apply d owner an oof e q p
property who builds o im prom derstn,and who does such work himself err though his
own employees,provided thatsuch improvements art not Intended oronem7 forsale.IL
however.the building or improvement I.sold wid io one year of completion,the owner.
builder will have die burden of proving that he did rot build or improve for purpose of
sole.).
❑1,As owner of the Property,am eaclwiwly conuuting with licensed conammo w
construct the pmject(See.7044,Business and Pmfe rsiom Cade)The Conuxm's U-
cove Law does not apply to an owner of pmpeny who builds or impzem demon,and
who contracts for such projects with a conuacmr(q licensed pursuant he de Conusxafs
License Law.
❑I am exempt under Sec .B St P C for this mann
Owner Dau
Adfils WORKER'S COMPBNSATION DECLARATION
1 hereby a Too under penalty of perjury one of the following declaadom:
Ilowand will meinuine ceNfiesteorCovent as self-insure far. Wm1me Compcm-
Ander,As provided for by Section 3700 of the labor Code.for the performance of the
wart for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of de lobo Conk,for the performance of de wort fur which this permit Is bound.
My Worker's Cnrtpgnsaths.Zea a artierand Policy.,unkl sec:
GMer.g �—TT.a" Policy No.:ySO " a4-o
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This xnian need nothecampleud ifthe permit is farom hundred dollars(5100/
v Less.)
1 certify that in the performance of the work for which this permit is issued.)shall not
employ any person in my manner m As m become subject to the Workers CompemNon
Laws of CsIifomla Das
APPlkant
NOTICE TO APPLICANT If.after making this Certificate of Exemption,you ahouk
become subject to the Worker's Compensation prevision,of the Labor Code,you most
.,Z faMwid comply with such provision or this permit shall he deemed conked.
z CONMUC71ON LENDING AGENCY
(-i hereby arum thou them taaeorutroctinn lending agemy for the performance of C
(>r> the work for which d'u permit ts issued(Sec.3097,Civ.C.) ////'/' fr•I{/�_/
W.Q Lender's Name
6. ress
0. z Lander',Add
U Q I«nify that 1 haw mad thin applications bo
and suss dthe ave information is
U,!! torten.l Sm to comply with all city and county aNin,nas and sou law,minding toQ`SJ' buildingcovWction,andherebyAuthorizerepmxnudmofthiscitysenowopende
[37 ahow-mentioned properly for ivpccdan purposes. -0—i!F^y py (We)agree wtaw,indemnify and keep bersom due City of Cupertino sound �w
ti f/f Ilabili0n,judgments,tam and expenses which may in Any way xrne sgaivt said City
V f7T in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON-POINT Issued by: Date
SOURCE RA�E ggUL�o� �
—fj li`�Nj Re-roofs
Sigvtumo pplicartlCa mr Dam
H us MATERIALS DISCLOSURE Type of Roof
Will the applicant err future building occupant utero or handle ha t doss material
As dented by the Cupentao Municipal Code.Chapter 9.11,and the Hcaltb and Safety
Coda Section 15531(.)7 All roofs shall be inspected prior to any roofing material being installed.
Dyes
Will the applicant at future building enchant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
colt harardou,air contaminants As donned by the Bay Area Air Quality Management all new materials for inspection.
Dista c@
(]Ye, Lyam
I haw mod the huAdam mm6aismquimmenu under Chzpwr6.95 of the Calitm.
ria HAnldk Safety Cade,Scaom 25505.25533 am125534.1 undcraued Ihuifde building
dem rot currently hew a tenm4 ds It u my mapomlhilitY w rwdl'y 0s.omumem of ds
requlmmenncate afoecupaney. Signature of Applicant Date
u whi mel pdorwi anus err.cmti
Owner or au ori>ma rot Dam All roof coverings to be Class"B" or better
Community Development
10300 Torre Avenue
6 Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
IUPEkTINO
Building De artment
JOB ADDRESS:Z�Z 7Z �0. A PERMIT #
OWNER'S NAME: PHONE # Z-D 5 -33
GENERAL CONTRACTOR: (� FAX #
I am not using any subcontractors Z/2 Y/0-5
Signa&re Date
Please check applicable subcontractors and complete the following information
60 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 /
Owner/Contract r Signature Date
CITY Of CUPERTINO o� 6 17
WATER HEATER 1
CUPOEkTINO PERMIT APPLICATION FORM
APN# 3 / q O Date: 2 y/o S
Building Address: 20 27 -z-
Owner's
Owner's Name: Phone#:
I�,yc.,2a,�Q V.%/.Ca..2�,t,-�. Z 0-5 -3-314 9
Contractor: Phone: License#:
� 80d 813 5 - 59 y 6 3 -74S -7--i
Contact: Phone: � — Cupertino Business License#:
a>
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project:
Strapped On Platform 0
�( Bonded
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMTTFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING