05120074 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTORtINFORMATION
BUILDING ADDRESS: AFFORDABLE WATER HEATERS P"""N0.05120074
22031 RAE LA
OWNER'S NAME: PERMIT ISSUE DATE
GREEN WINFRED JR AND TERESk 24707 SAN FERNAND D 12/14/2005
NE: SANITARY NO. CONTROL NO.
(661) 259-7131
ARCHITEC rENGINEER: BUILDING PERMR INFO
BLDG ELECT PLUMB MECH
0 0
uo00 LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Nat 1 am licensed under previsions of Chapter 9(commencing Job Description
with Section 7")of Division 3 of the Business and Profession Code,and my Iicemn is
o ina
OtBformandeff Lm g REPLACE 75 GAL. WATER HEATER
Li<cn
o ARCHTECD-S DECLARATION
ECLARA I N k G '
� 1 undersand my plans shell he used as public rcrnNs
DaU
ky Licensed Professional
OWNER-BUIIAER DECLARATION
iI 1 hereby affirm that 1 am exempt from the Convector's License Law for the
00 following mann.(Suuon 703 L5,Business and Pmossion Cade:Any city or county
2 which requires a remain to construct,alter,improve,demolish,or repair a.Y suuctme $400
—iy prior to its issuance.also requitu the applicant for such Permit to rile a signed statement
<
road lux islicensed pursuant mthe Pownionofthe Conuxar,Lice selaw(chapter9 Sq.,Ft. Floor Area Valuation
YFp (commencing with Section 7000)of Division J of the Business and Profusions Cutlet or
y that he is exempt therefrom and the basis for the alleged exemption.My violation of n
Section 7071.5 by any applieun for a permit subjects the applicant to a civil penalty of
not more Nan five hundred dollars(S50(), r yAOccupancy Type
C]1.as owner of the property,or my employe=with wages as their tele compensation, /e // Al
will do the work and tiro trumure is not intended or offered foralc(See.7061,Booms. � S
and Profession Code:The Contractor's Lian =not apply to an owner of �e Law tloIn peiio
property who Wilda mimpmves then o t,andwho dmsamh work himself orthrough his v
own employees.p building
or i provehimprowmentsaane year mdWoroltion.for sale.If. O
huilder,Nebuildinguimprovementismid within one year of completion,the owner- is
builder will haw the burden of proving that he did not bulb or improve for purpose or (/
sale.).
❑1,as owner of the pmpeny,am exclusively contracting with licensed convectors to
construct
nt dm es not apply
7814,weer of and ray who
Cade:)The Cs,themor's In-
ane law does not apply e ts owner of property,who builds or improves Coreon,and
whocontractsLaca for such projects with a conwcmrts)IiccmLad pursuant m the Convatab
License
❑lam eaempn untl=S=. ,Bk PC fm Nix me=an
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury aro of the following declarations: _
'\ Ihaw end will meinuina Cenifiaaa(Co,anttoalf-insure fm Wotkcls Compere
union,as provided for by Section 37W of the labor Code,for the performumc of the
work for which this Permit is issued.
❑1 have and will maintain Worker's Compensation Buura ce,u required by Section
37W of the labor Code,for the performance of the work far which this Permit is issued.
My Worke'sn Ip'Tn(� 90lnamvx umm and Poll cyn tuber art: m
Cormier 1•y' �/.�p.r✓I� PolicyNO.: 3f'=`z. )
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
Couls action need no Wcompleted from Permit is for one hundred Johan($100)
or lcsa)
I certify that in the performance of the work for which this Permit is issued,I shall not
employ any person in any manner an u m become mbkn re the Worked Comrewuon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Ccnil eam of Exemption,you should
b=ore subject on the Worker's Compewtion provisions of the laMr Cad,you muse
.J O forthwith comply with such prevision or this Permit shall be doomed revoked.
z CONSTRUCTION LENDING AGENCY
[—a 4 l he
rebywhich thi that there is ed(Sm.3W7,ding agency for the Performamc of
C4'7 the work for which Nu permit u iuuctl(Sec.7097,Civ.CJ
U=z Lender'..Name z Lentleri Address
U C) I certify this 1 haw read this application and sate that the above infomudun is
D.r. COMM 1 agree to comply with all city tib county ordinances and state laws relating to
DU building convection.and hereby Authorim representatives of this city to enter upon the
�+a above-mcntianc0 Propcny for inspection whims=.
f-' (We)Agra to ave,indemnify and keep leatmlc s;the City of Cupertino aSaint
liabilities,judgments,costs and expense
-
fn s which mar'in any way eccrvc agaimmu to City
Uz in consequence of Ne granting of this Permit.
APPLICA UNDERSTAND AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S ' G LTIOlS ! y /
YY�' �2j !� Re-roofs
Signature of Appli _HAZARDOUS MATERIALS DISCLOSURE Date Type of Roof
Will am applicant or fissure building occupant atom orhandle harudoa material
a tic6rmd Ile Cupertino Municipal Code.Chapter 9.12 and the HcaN and Safety
Code,Seb'..i255J2(a)4 All roofs shall be inspected nor to an roofing material being El Y. t7L16 P P � Y g g installed.
Will the applicant orfuture building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
=
it hafdous air contaminants a ncd by the Bay Area Air Quality Management al I new materials for inspection.
isvics?
❑Yes Nu
1 has mad the hvardeesma crialstcquirements under Chapter6.95 alike Califor.
nix Herd"Safely Cade,Smuon255(6.25533 and 25531.1 understand thuifum building
docs not currently vc tenaL OAl II u my mspomihility to notify de occupant of thc
meghire �lr be`Yprin uantta(aCerdfi=mar P=rey./ Signature ofApplicant Date
/2 �7/
Owner or amhomed agent All roof coverings to be Class"B"or better
pea
11/23/2005 08:49 66122599556 AFFORDABLE WATER HET PAGE 03/03
CITY OF CUPERTINO O S
WATER HEATER
OF
CUPRKT[NO PERMIT APPLICATION FORINT
APN# —
0-7 — �—7 Trate j 2 — `�_ D—!
Building Address:
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Owner's Name: Phone#i:
W;n FrPa 6�C¢n o�- a5'a . '1$76"
Contractor: Phone: �rO l License#:
ab e a e eaTe�s ssl -1 ► cva-7 3L8
Contact: Phone: (c b{ Cupertino Business License#k:
cou L-i1T 0-h'eld 5 o�av a�gsn
Building Permit Tnfo:
Bldg ❑ Elect ❑ Plumb Mech Cis
Job Description:
{�ePIGC.e 'js atlon WA'►"er bleaTer [5ctme IoCATi9n
Residential Commercial ❑
Cost of Project: q o 0
• Strapped On Platform ❑ Bonded D
New Location ❑ R5placement
Qty. if
Applicable Fee ID Fee Description Fee Group
$MTEA ER Water Heater I Vent BUILDING
PPfiRNIITFFE Plumbing Permit Issnance PLUMBING
BENERGY Ene BUILDING
BUSLIC Business License SUIT RING