05050091 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT .$CONTRACTOR INFORMATION- °;
euILDINO ADDRESS: WATER HEATERS ONLY PERMIT N005050091
10? CIEDIATE W:9
• OWNER'S NAME: PERMfI'611EDAT8
ONE: SANITARY ITC7 CONTROL NO.
I
CHITECT/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Q
LICENSED CONTRACTOR'S DECLARATIONJI hereby affum wt I am Hanged on&,provisims of Chapter 9(cumemennQ lob Description
Semian]Og17o(Diviaion Softhe Budnm uM Profetium Code,and mylicem is ����� ®mnrame.rbe 13L Lma{5 REPLACE WATER HEATERLleenae
Lt. Da¢ O nlr
9e ARCH
1 undenland my plana shell he used u public rt..,or
3` 4 2 2005
Licensed
OWNER-BUILDER DECLARATION
E0 2 I hereby.(Sere onn 1 am uusin from due Coneecmr'a License Law for the
E02 Following rtunn.(Section]1D L5,Business and Pmfeuiuro Code:Any city or county
n3 which requires a Permit to common.after.Improve,demolish,or repair any armature III MIL
I Zp prior it)is iuuance,elsu requires:tbo.pplicmt fonuch permitmele&signed statement Wimp
�< dist he is licensed pursuant to the prevision of he Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Vh1ultiaffaw
9 (commcncingwiNS cdon7800)of Divisim3of the Busincuud Pmfmiom Cade)m
55 that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Secdo07031.5 byanyapplicantforapennitubjecuthe appliantmacivil penaltyaf 3 ]Tib@r00 Occupancy Type
not mon than five hundred dollars(55001
❑1,o,ownerof the propcny,ar myemployees wisherml(er is(Sm. 0",B udam,
will do thewwh,seder he cture ComsnmsLlcerdofnwdoess nt apply to an owner
Required Inspections
usiness
and erywhobu Cade:The C shnesrt Llama law des ore apply If an owner of q p
own enywhas.preroded that such
who duesuchwort or
his
own employes,provided that tench Improvement in not ars Of
m offered forMe sale.IL
however,Nc building or improvement Is hath a did one year of mprove f r the owner-
"to).r will haw the burden of proving that Ire did ret build m improv for purpose of
uic.).
❑1,u owner of the property,am exclusively contracting with licensed consacWs m
construct W project(See.7044,Business and Profession Code:)The ConuacroY(Li-
cense Law does not pply to an moor of property who builds or Impresser daemon,and,
who contracts for such project wish a eonuacter(s)licensed Portugal to the Can iclors
License Law.
❑1 am attempt under Sec. .B k P C(m mi.moan
Owner Data
WORKERS COMPENSATION DECLARATION
I hereby affirm under penury of perjury,aro of W following dnclen6on:
1 have end will malnsin a ceNfia¢areomcnt to self-Inure fmwmkeY(Campcn-
lation,u provided for by Section 3700 of W Labor Cade.fu W performance of the
work for which this permit Is issued.
❑1 haw and will maintain Walkers Compensation insurance,as required by Section
3700 of the Lobar Code.for the performance of Ne work fn which this permit is issued.
M Wad�r I C/q�rcn�pian In u r a�nndppoli numbenre:
c.mm:C's L.ik.Tw.. n "'�or'Y Na dS-t-VSQ3—o�
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
MIS eeniml reed mnaccomputed if tbo permit is Faroe hundred dollars F$100)
or len.)
I cenify that in the performance of the worts,fm which this Permit u issued.I shall nm
employ any person In any manner an as m Wcomoubject to W Workeri Compemtlon
Laws of Callforela.Date
Applicant
NOTICE TO APPLICANT:IL after making this Ceddfcam of ExemPtion,you should
become subject in the Worker'(Compemadan provWon of the Labor Code.you rent
.J O Forthwith n
with comply wide ch provisions or this permliSbe hot] deemed makes.
CONSTRUCTION LENDING AGENCY
�-. I hereby affirm that users,is a contraction lending agency for W performance of
�i the work for which this permit s issued(Sas.3097,Civ.C.)
QLenders Name .
z Lenders Addran
V Q 101111Y Nat 1 haw rated she application and sum that W(how information is
ly F cored.I agree m comply with all city and county ordinances and sum laws relating m
O V building construction,and hereby uhorim representatives of this city m emu upon the
L[1 .hove-mendoned property for inspection purymss.
QL (We)agme,ha save.Indemnify and keep humless the City of Caparison against
rA liabilities.judgments.cots and exposses which may N my way amxnc.gaimi acid City
V 7 in camgnnee of the gorillas of this permit.
F7 APPLI UNDE A B AND WI COMPLY WITH A 00 PO Issued by: Dale
sou ecu
�7�G� Re-roofs
Signature of
HAZARDOUS AppeaRate
MATERIALS DISCLOSURE Type of Roof
Will the eCupentn forum boat Coe.Chape nomor hurdle Nsalloanmateritl
as ticfined by the Cupertino Municipal Code.Clupmr 9.12.and W HaIN and Safety1.0k '
Cade,Scc❑don 25532(()7
ON. All roofs shall be inspected prior to any roofing material being installed,
Yen
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 Nanrdnm air con.ral ans as,darned by W Bay Area Air Quality Management all new materials for inspection.
D
istrict?
Oyer ON.
I have read the hunNmr materiels requirements under Chapter 6.95 of the Califon
Health A,Safety Cade,Section 25505.25533 am125534.I understood Nu 11 dte building
oot c ntly have a moan t h s my respamihility w notify dee aceupanl mf the
Signature of Applicant Date
All roof coverings to be Class„Braor better
ner umm�oriactl spam Dam
Community Development
10300 Torre Avenue
R Cupertino CA 95014
Telephone(408) 777-3228
C f Fax(408)777-3333
�UPE(�TINO
c� BuildingDepartment
JOB ADDRESS: ! Q! Q Z ao alk- LA J w�, PERMIT# n S-0 S 009 /O9 /
OWNER'S NAME: I PHONE # a S -7 - (, 5 -7
GENERAL CONTRACTOR: .a FAX #
I am not using any subcontractors: L3
Signature Date
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
xi-4 o
Owner/Contractor ignature Date
CITY OF CUPERTINO f g
WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN# 3 -2-- 6 — S _ Oil Date: G_l ' 7 /O S
Building Address: C ' /
/O /O 2-
Owner's
Owner's Name: Phone# S 7 —t/ ` s 7
Contractor: Ph on License#:
(,�a$w �� . �c �j'W F35 -59q6 3 s7 ,3
Contact: Phone: Cupertino Bus ss License#:
017
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: 9�0 9 n �q
Residential Commercial ❑
Cost of Project: nao i
Strapped El On Platform LJ
yj Bonded El
New Location ElReplacement '
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
/ PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING