03100069 (2) "CITY OF CUPERTINO
BUILDING DrvlsloN: PERMIT ICON—RACTORAN ORMATIQ�1 '`
nml,DING ADDRESS: HOT WATER INC PERMIT NO03100069
03100069
OWNER'S NAME: 2531 GRACELAND AVE PERMIT ISSUE DATE
NE: OONTROLNO.
(650) 298-8494 SANITARY . C
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
sop LICENSED CONTRACTOR'S DECLARATION'
C I herchy'from that 1 am licensed anter provisions of Chapter 9(commencing _ Job Descriptlo.n
w with Section 7MB of Division 3 of me Business and Professions Cedc,antl my license is
o. in full force and oft
;�"3 ueenseelamm L 3 (�Lm,« '��S, 3 L / z WATER HEATER REPLACEMENT
,Fp Date. IT Contractor ■ 11YAY�.®
',f` ARCHITECTS DECLARATION ■
I :� I undersand my plans shall he used as public records
5yu
at-' Licensed Pmfes'ianal APR 1 2 2004
OWNER-BUILDER DECLARATION
<IE I hereby affrm that I am exempt from the Contractor's License Law for the
p O following reason.(Section 7831.5,Business and Professions Code:Anycity or county
f Z which requires a Permit to construct,alter,improve,demolish,or repair any structure
Her m its issuance,also inquires the applicant for such permit to File a signed statement
< 9 00
that he is licensed pursuant mThe previsions ofthe Connector's License Low(Chapter 9 Sq.Ft. Floor Area Valuation
2 $ (commencing with Section 71ks0)of Division 3 of the Business and Professions Code)or
..
that he Is exempt therefrom and the basis for the alleged exemption.Any violation of 32648034 - 00
Section 7031.5 by any applicant for'patent subject the applicanno a civil penally of APN Number Occupancy Type
not more than five hundred dollars($5M).
1) y yp
I,as owner of the property,or my employees with wages as their sole compensation,
will do Ne work,and the stricture is not intended or offered for sale(Sec.7094,Business 5U2-- FINAL Wj @14RcgNWRGY
and Professions Codc:The Connector's License Law does not apply m an owner of
property who builds or The
Nercon,and who doessuch work himselfor through his 506 — GAS TES
own employees,provided that uch improvements are not intended orolfemd for sale.If. 507 — FINAL PLUMBING
however,Be building or improvement is said within one year of completion,the owner
builder will ban the burden of proving that he did not build or improve for purpose of
Site).
❑1,as owner of the property,am exclusively contracting with licensed Contractors m
consumer the project(Sec.7011 Business and Professions Code:)The Contractors Li.
cense Law does not apply to an owner of property who builds or improves Neuron,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License
w
m
Le .
1 aexempt under Sec. .B&P C far his rcsson
Owner Data - -
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the fallowing declarations:
1 have and will maintain a Certificate of Consent to self-insure for Workers Compcm
sation,ax provided for by Section 3700 of dre Labor Code,for the performance of the
work for which his permit is issued.
1 have and will maintain Worker's Compensation Insurance,m required by Section
W of the Labor Code,for the performance of the work for which Nis permit is issued.
My Workers Compensation Insurance carrier and Pal icy number art: 6 II
Carrier. S r IATf. Policy No.:/ a1 f�n.-�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permil is foronc hundred dollars($100)
ter less.)
1 certify thin in the performance of the work for which this Permit H issued,I shall not
employ any person in any mannerso u as become subject to the Workers'Comperoation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the L'bnr Code,you must
7Z foMwith comply with such pfnvisionsnr this permilshall be deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the Performance of
:4> the work for which Nis permit is issued(Sec.3097,Co.C.)
Q Lendces Name
Z Lender's Address
p 1 certify that 1 have mad this application and sate that Ne above information is
4. Htorten.1 agree to comply with all city and county ordinances and mute laws relating to
V building construction,and hereby authorise representatives of this city to enter upon the
a above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino sgainsl
N liabilities,judgment,cost and expenses which may in any way accrue against said City
J 7 in consequence of the griming of this Permit.
r7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCES�FFFt'�UULJs�T({�ONS.'�`,
!!!U S4
Signature Of Appy Iicant/Contr-aScai \ p.lo� Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle haterdaus material
as defined by he Cot enino Municipal Code.Chapter 9.12,and the Health and Safely
Code,Sc❑cYorn 25532(')? No All roofs shall be inspected prior to any roofing material being installed.
Will Nc applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
sit hazardous air contaminant as defmcd by the Bay Arca Air Quality Management all new materials for inspection.
istrict?
❑Yes qNo
1 have mad the haaaNnus materials requirement under Chapter 6,95 of the Califon
nia Htmlth&Safety Code,Sections 25505,25533 and 25534.1 andmomd that if he building
docs not currently have a tenant that it is my responsibility In nodl'y the oecupanl of the
requiremcntsw l III lWm ui5saanccofacmarcat Of Oec Cy/v Signature of Applicant Date
C, V le All roof coverings to be Class "B" or better
Owner m aaiherind'gem ale
1
CITY OF CUPERTINO
WATER HEATER 03 / ' U " �9
• CUPEI�TINO PERMIT APPLICATION FORM /
APN# Date:
324 0 03 �6 0
Building Address
Owner's Name: �Q P081 ?r X68 ''3
Contractor: P 0sLicense#:
Contact: P Cupertino Business License#:
� ��9v� Sol
s
Building Permit Info:
Bldg ❑ Elect ❑ Plum Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project: of
• Strapped Li On Platform AID Bonded El
New Location 1-1Replacement
Q
A ty.l iblq Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMrrFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License" BUILDING
� 23 4.32
S