03120076 (2) t CITY OF CUPERT INO s*♦
BUILDING DIVISION PERMIT COt\ J.R[1CTOIZ yINFORMATION d}'
B GILDING ADDRESS: HOT WATER INC PERMIT NO 03120076
OWNER'S NAME: PERMIT ISSUE DATE
NO.
ONE: SANITARY CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 = 0
400 LICENSED CONTRACTOR'S DECLARATION Job Description
0 1 hereby affirm that 1 Am licensed under provisions of Chapter 9(commencing p
�E with Section 7")ofDivltlon 3 of he Business and Profcumns ode,and my license is -
n inlull f°rtean f= REPLACE WATER HEATER C'w,�`�O
gp
Licari.
ata C ic.a r ,�Y
g DateCunlractor 1 a
9 A CHITELTSDECLAR ON
1 A d y pia hall M scd es public records
r4 02
;0 LicenudPre ma JAN 6 2004
OWNER-BUILDER DECLARATION
.� S 1 hereby affirm that 1 em exempt from the Contractor's License Law for the
po following reason. 71A L5,Business end Pmfcssinns Code:Any city or county BUILDING
k 2�N which myulres A permit n,consdeel,alter,improve,demolish,or repair any structure
LZT poor In its issuance.also requinis the applicant for Such permit In file a Signed atalCmenl
p <
that he is licensed pursuant oNeProvisions ofthe Contractor's LicenceLaw(Chapter 9 Sq. Ft. Floor Area Valuation
yF❑$ tommencingwith Sation7000)of Divislon3ofiMBusinasand Ponfeui.ns CM1c)or
3.. Net he is ex°mpl dlem(mm And Ne basis for Ne Alleged exemption.Any Aredo.of roe riaxirwn�ca,,�
Section 7031.5 by any applicant for s permit subjects the Applicant to a civil penalty of 3�1Y?S WDl UO 0 Occupancy Type
nm mart Nan five hundred dollars(55007. P Y YP
❑1,u owner of the property,Or my employed with wages u Their sol°compensation,
will do the work,end Om net..is not intended or offered for sale(Sm.7044,Business
anRequired aired Ins eCtlOn$
And Prefcohm,Code:The Contractor's License Law does not apply to An owner of q p
property who builds or Improves thereon,and who doeuuch work himself orNrough his
own employees,provided that such imprmcments are not immnde l oroRered formic.If.
however.the building or Improvement is sold within one year of complcuon,the owner.
builder will pave Ne burden of moving that M did not build or improve for purpose of
sale I.
❑1,a owner of Neproperty,em exclusively contracting with licensed conuaaors to
construct the ponied(Sec.7014.Business and Professions Code:)The Contractors Li.
Cense Law door not apply to an owner of property who builds or improves Nemon,and,
who contracts for such projects with a contnemr(s)licensed pursuant m the Contractor's
License Law.
❑1 Am exempt under Sec. B k P C for Nis rtuon
Own Date
WORKER'S COMPENSATION DECLARATION
I hereby Affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self-insure for WorkersCompcn-
mtion,As provided for by Section 37M of the Labor Code.for th=performance of Ne
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,As required by Section
3700 of the Labor Code.for the performance of dm work for which Nis permit is issued.
My
Workers Compensation Iuunnce artier and Policy number rt: /
Camcr. ��9&'C/;oicy No.: tUJ/c/
1 KATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissection raced not M completed if the permit it for one hundred dollars(S IIX1)
or less)
1 certify that in the performance of the work for which this Permit is issued,1 shall not
employ any person in any manner s°As to become subject to the Workeri Compemallon
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:if.ager making his Comficare of Exemption,you should
become subject to the Worker's Compensation provisions Of the labor Code,you must
.JO forthwith comply with such Provisions or Nis permi I shall be deemed mvnkad.
Z
a r CONSTRUCTION LENDING AGENCY
N
r+ IhcaRrm Nal there itacoutmclionknding agcrrcY for the perfurmantx of
the work No
whor which this permit is iuucd(Sec.3097.Ci,C.)
WM A Lcndcr'a Nam.
] z Isnder's Adtlmss
U Q I Certify that I have mad Nil application and Tao:Nat the above information is
Ii F correct.l mgrce to comply with ill city And county on inancea and mid laws relating to
0 huilding construction,and hereby authorise representatives Of Bia City to enter Orion the
W above-mentioned property for iupection puHmses. vs
ky,s,gy (We)agree to save,indemnify and keep harmless the City of Cupertino gainat
,`..m Eli liabilities,judgments.costs and expenses which may in anyway accrue against mid City
UZ I. minumuencc of the granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R,aQI1.O,/ S. QO /6�
Signat (7ad P
ure o(Applic.r d �7V/D-�--- Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building oecupmtslore orhandle hamsdous mambas
As de0ncd by the Cupenint Municipal,Code.Chapter 9.12,and the Health and Safely
Code.Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
Yu
Will Nc apPlicanto' r°I°m°hudmns occupant tr:c equipment or devices which -If a roof is installed without first obtaining an inspection,I agree to remove
it h.,.21 us air comaminanss as Joined by the Bay Arca Air Quality Management all new materials for inspection.
❑secs /[meq
I have read the havanrml rramrials bepiamenuunder Chapmr6.95°fthe Calif. '
nia Health&SafclyCedc.Sceuou 25505,25533 And 25534.1 understand NmiflM Wilding
does not currently have a IWanl.but it is my responsibility In noul'y tic mxupanl of Nc
rcq them c sl he prior m issuance of a C,,Mficatc of Q m
°}cep 7? 71 x3 Signature of Applicant Dale
ownderaann xmascat ('� Ate All roof coverings to be Class "B"or better
-I
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CITY OF CUPERTINO Z 7
anal WATER HEATER v 3
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
IZ1003
Building Address:
aioG � � Cfi
Owner's Name: Phone#:
ti 08 Zs-S- 5�sr,--�
Cot tor'. Phone: &50- 63/- XOy License#:
Geer � V1� . .1 .-^ `_7 &.5(p(�—
Contact: Phone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: zz, �
Residential Commercial ❑
Cost of Project:
• Strapped ❑ On Platform ❑ on ed ❑
New Location ❑ Replacement
Qty.. if
A l' a Iq Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
IV PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
4r 6