04050111 (2) CITY OF CUPERTINO �'77.77-777'7'7'7F777
BUILDING DIVISION PERMIT CONy," TOA INFORMATION
BUILDING ADDRESS: HOT WATER INC - PEIIMIT"(4050111
77 PUMPKIN OT
OWNER'S NAME: PERMIT ISSUE DATE
HALCYON MCINTOSH RA
ONE: SANITARY NO. CONTROL NO.
650) 298-8494
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u p C LICENSED CONTRACTOR'S DECLARATION, O
1 hereby affirm that 1 am licensed under provision of Chapter 9(commencing Job Deseripti
a< with Section 7000)of Division 3 of NC Beeinenandlinume'um,C d),andmylicenmis
Yrs anise arta.trace 1-Z REPLACE WATER HEATER
H, Licen�Coal bor
H,
Date GanDECL NOV 23. 2004
A HffECse DELLA A
1 unticrsmnd my plats shell he used a public records
It
z ° BUILD(
C I Licensed Professional BUILDING
3 OWNER-BUILDER DECLARATION
0 0 1 name .(lura on 1 em exempt from d r Cnnlns License c Lew for the
0 0 whichindicating muoa .anti to cons S, ,,Business and Profusions h,or Code: no city at muctury
$ which its requires s a permit re cons=,,the alma borrow.for
demolish,m repair any xwment
priorroitscense pursuant
requires the
sof the Contractors
rofile
ense signed statement
££
that hmencigwithSrsuant700the ofDiaionat3ofMe0ush70sandprofesonCode)atapter 9 Sq.Ft. Floor Area Valuation
Y�$ MIL he is
(commencing runabout
ad the
basis
r the
al eged ass ipt on.Any
n y vi Code)of
MIL he is exempt therefrom and Ne buts for the ellcgctl Gumption.Any violation of
Said.7031.5 by any applicant for a permit subjects the applicant to a civil penally ofCro 0 Occupancy e
oat mase Nan five hundred dollen(S50o1. Y TYP
❑1,uowner ofthe property,or my wnploycet with wage.as their ulecampensation,
will do the work,and Om Mucsum is notintended ofoffered foraam(Sec.7044,Business
and Professions Code:The Contractor's License Law docs Out apply 70 an owner of Required Inspections
property who buil ds or i m proves thereo n,and who does such work himself or through his
awn employees,provided thalaueh impronments are notimmnded or offered(anile.If,
however,the building or improvement is sold within one year of complearon,the owner-
builder will have Me banden of praying Nat he did not build Or Improve for purpose of
sale.).
❑1.as owner of the property,am exclusively contracting with licensed contnclora to
cautraat the project(Sec.7044,Business and Professions Cade:)The Contru70re U.
cave law docs not apply to an owner of property who Wilds or improves themon,and,
who contracts for such projects with a eontrumr(S)licensed punum to the Comactorb
License Law.
❑I am exempt under Sem ,B&P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affhm under penally of perjury one of the following declantimns:
1 have and will dommin a Certifieam ofConunt to self-intim for WorkeYsCompen-
Milan.u providetl for by Section 37011 of Ne labor Code,for the perfmmence of Ne
work for which this permit is issued.
&hue and will am mal.Worker's Compensation Insurema,as required by Section
of the labor Code.for die performance of the work for which this p)nnit is issued. . .
My Wmkar' ompmsadon insurance omler and Policy number are:
Cartier: Polity Nu:
E TIF( A OFEXE PI7ONFROM WORK: S'
COMPENSATION INSURANCE
rlTis secdon need not be completed if the recall is formic hundred dollars(SIM)
or less.)
1 certify that in the performance of Ne work fm which this permit ts issued.I shall not
employ any person in any manner so u 70 became subject to the Workers'Compenaefica
Laws of Caliromia.Date
APPlianl
NOTICE TO APPLICANT:If,after making Nis Ccmifmam of Exemption.you should
became Subject m Ne Wo leer's Compensation provisions of the labor Code,you must
J Z forthwith comply with such provisions or this permit shall ho deemed revoked.
EO� CONSTRUCTION LENDING AGENCY
[-+ I hereby afLm Net diem is a construction lending agency for the performance of
gY > Ne work for which this permit is issued(Sec.3097,Civ,C.)
W� Q Lembus Name
] z Lenders Address
U Q 1 certify Net 1 have mad this application and state Net the aboa information is
I7.f+ correct.1 agree to comply with all city and county ordinances and sum laws relating to
QU building construction,and hereby adNarin mprraentsuvcs of this city to enter upon Nc
W shove-mentioned property for expenses purposes.
LL (We)ague N rave,indemnify and keep humleu dm City of Cupertino against
to
in
f Me granting
expenses ptrnit, may in any way.carve against Mid City
U',[ A APPLICANT
of the RSTA of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RETGULA72S. a /If/
u ti Re-roofs
Signature afA plicard/Contracto fM¢
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the epplicarn or future building Occupant stare or handle havardous memo&]
u defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
ode,sc❑ctive
es z5s3z(an All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It handouts air coomminents u defined by Ne Bay Area Air Quality Management
Distfict7 all new materials for inspection.
❑Yes R}Nu
1 have mad the h roodous materials requiuments under Chapter 6.95 or the Califor-
nia Health&Safety Crude,Satiou 25515,25533 and 25534.1 understand Naz if the building
docs not cuncmly have a tenant,Nat it is my uspouihility to notify the accupen or Ne
mquimmcnyAyllrn�xlnLtphmwis�pamaafaccrdnMba roe tyy_/,Qy Signature of Applicant Dale
Ownma�6rau ofte(tl/�gent//��,,�[,(/ / aam—T All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
. if ' ' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
OWNER'S NAME: PHONE # j)
GENERAL CONTRACTOR: -Vt a,"(, FAX #
I am not using any subcontractors: 11,_C,�,oc.ta C.$11 9J6 LY
Signature ate
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
Owner/Contractor Signature ate
10/28/03
1
CITY OF CUPERTINO
WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN# 2 _ 2— -Q , /`jp Date:
G 1 d
Building Address: -7 �
Owner's Name: 1 /,, ,, e i � � Phone#; a5 �3
pN ��(
Contractor: Pho e: License#:
HOT WATER INC. -7
Contact: SAN CARLOS, CALIFORNIA 94070 Phone: Cupertino Business License#:
a 1
Building Permit Info:
Bldg ❑ Elect ❑ Plumb YX Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project: X50
CD
Strapped El On Platform ElBonded
New Location ElReplacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMTI'FEE Plumbing Permit Issuance PLUMBING
y BENERGY Energy BUILDING
BUSLIC Business License BUILDING