05120135 (2) CITY OF CUPERTINO ,
BUILDING DIVISION PERMIT x4CONTRACTORINFORMATION
BUILDING ADDRESS: PERMIT NO.0 5 120135
OWNER'S NAME: PERMIT ISSUE DATE
THOMAS D W 12/22/2005
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
u0o LICENSED CONTRACTOR'S DECLARATION
I kmby affirm mar I am licensed under provislov of Chapter 9(commencing Job Description
with Section 70(0)of Division 3 of the Businosand Professions Code,and my license is
? y infullforeeandefrett REPLACE WATER HEATEp—
oD Ll 2z Liccve Class Lie.D �M, p gy LED
4l n Dam Contractor NA
IFfpsge—Haan
ARCHITECTS DECLARATION
D R I undcrsund my plana shall k used u public records
;LL� Licensed Professional
- :5 OWNER-BUILDER DECLARATION JAN �3 1006
<I I hereby affirm that 1 am exempt from the,Conuacmfs License Law for the
OO following reason.(kcuun 7131.5,Business and Prorcoi ins Cade:Any city or county ry�y
K S f<i which requires a Permit to construct,alter,improve,demolish.or repair,any structure ry y C,y` Liyl{, [g $750
LZi prior to remit its issuance.also requires the applicant peto file a signed summenr 4a r� nation
r
matkulixnsed pursuant to the Provisions oftk Contrxpr's l3ccvc law(Chapter9 S Ft. Floor Area(cia {; y
F G )rt= IY
Sq.
x e� that M-exempt Satfrom and th Divisiof rth al Bud cisim d Profeson.Any
Cade)or
that io u exempt therefrom and me basis for be cts On exemption.Any violation of
not na ]031.5 by Ary applicant for•permit subjects the applicant to a civil penalty ofAAR
over more Nan five hundred dollars(5500). r Occupancy Type
❑1,as owner of me property,a my employees with wages as their sale compensation,
will do the work and the sbuctum is notimended oroffeted formic,(sec.7064,Business
and Professions Code:The Contrsemrs License Law does not apply of in owner or Required Inspections
proper who builds or improves thereon,and who does such work h imself or through his
Own employees.provided thatsuch improvements are not intended oroBemA for sale.It. -
however,the building or improvement is sold within one year of completion,On owner,
builder will have the burden of proving that k did not Wild or improse for purpose of
Sale).
y,.
t `a owner of the property,am exclusively contracting with licensed contactors to
covwct the pica(Sec.7044,Buslnces and Professions Code:)The Conuations U.
revs,law does not apply in an owner of propanY who Wilds or improsv thereon,and
who contracts for such projects with a contractors)licensed pursuant in the ComnctoM1
LKenY law.
❑l oth manor,
udder Sao B&P-Cff ch n
Owner ;;el n)/J.a iin//, 'unalz
WORKEWS COMPWihSATION DECLARATION
1 hereby stacon under penalty of perjury one of the following dalanuov:
.1 have and will maintain aCcnificom of Consent in self-insure rot Wmker Compen.
soden,as provided for by Section 3700 of the labor Cade,for me performatta of the
work for which this permit is Wood.
❑1 have and will maintain Worker Compensation Insurance,as required by Section
3700 of On labor Calc,for On performance of the work for which this permit is issued.
My Worker Compensation Insuranx carrier and Polity number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not k complemd if the permit Is for one hundred dNlars(SI W)
mleuJ
I xnify that in On perfmmanec of the oh killwhich mus permit is issued,I shall not
employ any perroni ymannc o bjatW tk Warkeri ComPctuauon y
Laws of Califarni n' r Ol D
Applicant sr.m.n
NOTICE TO APPLICANT:If,after ingrBiis Ceniftcete of F..puon,you should
Worms subjmr to on Worker's Compensation provisions or the lalmr Code,you must
�z forthwith comply with such prnvisimn or this permit shall to deemed revoked.
zCONSTRUCTION LENDING AGENCY
[-� Ihemty,AMM that mere is a construction lending agency for the Performance of
C' the work for which this permit is issued(Sec.3097,Civ.C.)
0.25 Q Lcndels Name
.:T. z Lenders Address
U C) I ccoify that 1 have read this application and sole that dm akve information If
IL P-r comet.I agree m comply with all city and county ndicami and sate laws relating to
�U building communion,and herebyauthofbe representatives or this city to toter upon On
W akve-menudgm Proper for impccnem. drpwitch may
H O. (We)agree Id save,indemnify and keep harmless the City of CuPenino against
fA incoities.quonc of ents.
costs gramind ofpcnavwhich may in any way acme against saiO City
C„)z, meonsegnenec of me granting of this permit.
r. SOURCES UNDER TAN S AND WILL COMPLY WITH ALL NON- OINT Issued by. Date
Signoureof ApplicaMC n cmc ate Re-roofs
HAZADOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant nom or handle harudous material
u defined by the Cupenino Municipal Code,Chapter 9.13,and the Hcalth and Safety
Code,Section 25532(a)7
❑Yes ON. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant use equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hamolmou air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
10.,scrruintiffimixed
uict7
❑Yes C)NO
1 have read the hvu
adous materials ren
quiments under Chapter 6.95 of On Califor-
Health&Safety Code.Sections 25505.25533 sol 25534.1 undersund met if me building
n rpt cwcntly havea sen L Wt it is my mspovihility m notify Ike UWt of the
rom
uicn s which mu m a
ismac of a Cloolle m o Occup cy.
� 2
Signature of Applicant Date
get I I Date All roof coverings to be Class "B"or better
Community Development
f 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY 0, Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
1326 Sv �� Stelli ad Cyeo-djCp q5v141
OWNER'S NAME: oyn PHONE # Yo --5 3'— 853$
GENERAL CONTRACTOR: V P7 st t f b AX # qof - U 5 - J'7-q
I am not using any subcontractors:
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
zz za�5
er/ ontractor Signature ate
1
CITY OF CUPERTINO
WATER HEATER 05�-v,35
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
36(, - ll - 10-3fz�zz�zoas
Building Address:
1326 SoiA 5i2111n Qoacl , - CuP2rtlnoi CA R501q
Owner's Name: Phone #:
Thowma-6 D. VH Yob 3GT-,?5TS'
Contractor: /J License #:
3s6b
Contact: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ( Plumb Mech (�
Job Description:
H ev re to ce t
Residential Commercial ❑
Cost of Project: ` c�
• Strapped EC On Platform VJ Bonded
New Location ❑ Replacement
Qty. if
A plicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/ Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY EnergyBUILDING
BUSLIC Business License BUILDING