03120075 (2) r CITY OF CUPERTINO "`" 7,
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BUILDING DIVISION PERMIT CONTRACTOR INk ORMAT7pN:
BUILDING ADDRESS: HOT WATER INC PERMIT NO.03120075
224a r!0;2T_AR QRGV9 9Q
a OWNER'S NAME: PERMIT ISSUE DATE
NE SANITARY NO. CONTROL
'NO.
(rc;Q) 29R-R494
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
L � 0
X00 LICENSED CONTRACTOR'S DECLARATION lob Description
1 hereby art,,.the,l am licensed under provisions of Chapter 9(commcneing - p
R with SCC11rm70(Yd)rf Divi.km3of0m Busiveuand of norms Codri'mdmyliccnuis
or
rnLicense Clrmlmma aaA 1 /I //��/` � REPLACE WATER HEATER
s R,CS-L ld.p
i-❑
Data Contranor
A CHITECTS DECLARATION
pp 1 undery�id ai,p�lens shall he used erpublic nmol,
z Is
,d t illy
w0 License al
OWNER-BUILDER DECLARATION
af I hereby affirm that I am exempt from the Convector's License Law for the
C O following reason.(Section 7031.5.Business and Profession Code:Any city(ir county
which requires a permit to consume,,alter.improve,demolish,or repair any structure
yZ prior In its issuance,also requires the applicant for such permit to rile a signed statement
sa that he is imitated pursuant to the provisions Of NC Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
xa•� (commcneingwith Section 7")or Division 3 of the Business and Professions Code)or
s. Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicam for a permit subjects Ne applicant to a civil penalty of 3 ,A.HloT#Ta.�lr. FOO
nor mom than 11w hundred dollars($500). 'SS�aCC..'N ddVV'' ``YYe Occupancy Type
❑1,as owner of the property,or my employees with wages as their said compensation,
will do the work,and the swcture is not intended or offered for sale(Sec.7W4,Business
and Professions Code:The Contractor's Limned Law does not apply to an owner of Required Inspections
property who builds or improves d anion,and who does such workhimaelf or through his
own employees,provided Nat such improvements are not intended or,Bemd the oformic.r.
builder Neavetxorimprovementissoldwithin one yearofimprovefrNeowner-
hse.). will haus the burden of proving Nat he did no,Wild or improve for purpose of
salt.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to /
construct the project(Sec.]014,Business and Professions Code:i The Convector's and /
Genu law dins not apply,o an owner Business
who builds or improves thereon.and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Taw. O
❑l am exempt under Sec. ,B&P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury am of the following declarations:
I haw and will maintain a Cenirmate or Consent to sal Nostra,for Work,i a Compen-
7'311W"
on,asprovided for by Section 3]00 of the Labor Code.for Ne performance of Or
rk far which Nis permit is issued.
I have and will maintain Worker's Compensation Insurance.as required by Section
of the Labor Core,for the performance or Ne work for which Nis permit is issued Workr's om,xmsmion Insurance carrier and Policy num am:rver: U olicy No.:
DRIA ONFROM ORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the permit is form=hundred dollars($100)
or less)
1 certify that in the performance of the work for which this Permit H board.1 shall not
employ any person in any manncrsn as to become subject to the Workeri Compensatlon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,error making this Cenificnm of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you mus
,J ,z' forthwith comply with such provisions or this permit shall be deemed invoked.
Z O
NCONSTRUCTION LENDING AGENCY
r. Ihereb affirm Na,there is a consmctinn lending acne for the
H Y g 6 Y performance or
C(. e work for which this permit is issued(See J09],CO.CJ
L _
W� Q Lender's Nanta
F7 z L,ndeh Address
O C) I certify Nu 1 have read,his application and sum that the above information is
Is F-r correct.1 agree to comply with all city and county ordinances and sled laws minting to
0U building contraction.and hereby ashorin reprosenmhws of this city to enter upon the
U abow.mominned miserly for inspection purposes.
Ty (We)agree to aaw,indemnify and keep harmless the City of Cupertino against
N
liabilities.judgments,costs and expenses which may in any way getout against said City /
U in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Da[
SOURCj jgR9U TIONS.
G7 4&4 r/ I Z�ll3a� Re-roofs Sigrmurc ofAppi¢anUContractor ems—
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant sore or handl,havardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Heal lh and Safety
Code,Section 3y.a 25532(e)? No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant r f>�building occupant use equipment or devices which If,a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air conmminan s u defined by the Bay Area Air Quality Management all new materials for inspection.
4vicl? -
❑Yce ,❑Nit -
lhawreslNehaaa lues mamriaB requirements under Chapmr6.95rfNcCalifor-
niaHnith&SafdyCdk,Satire[s25505,25533end2553C.lundcrsmnd NatirNO Wilding
Jars not currently have a moral.Nat it is my insponibilhy to nodfy the Occupant of Ne
requirements wit musthem
prior suancc ofa Ccniif of Oce a_t,y/./ Signature of Applicant Date
owner arm^ ,call / r M. All roof coverings to be Class "B"or better
CITY OF CUPERTINO 1
WATER HEATER 15
3 Z`s"
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
) L+z 3 -3 02l IZ Io10�5
Building Address:
5lQowq Pa .I v- rD o c S •
Owner's Name: Phone #:
Con ractor: Phone: License#:
-7(a,50 a--
Contact: Phone: Cupertino Business License#:
a 3l
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: eot- e11—
Residential Commercial ❑
Cost of Project: Q0
. Strapped ❑ On Platform ❑ Bynded ❑
New Location ❑ Replacement fid/
Qty 'f
A ic' ble Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
fA PPERMTI'FEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
i