03060032 (2) CITY OF CUPERTINO ��" °�°'�^ '�'`
go BUILDING DIVISION PERMIT KCONTRACTaR4INFORMATIO
BUILDING ADDRESS: O ER INC PERMITNG03060032
11275 TERRA BELLA DR
WNER'S NAME: 2531 GRACELAND AVE. PERMITLt5915"3/2003
OWN CLYDE M JR AND NORMA F
14 ONE: (650) 298-8494 SANITARY NO. CONTROL NO.
t
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+�so� LICENSED CONTRACTOR'S DECLARATION lob Description
Ou F I MrobY a(Orm WI 1 am lite oder provisions of Chapter 9(.mmancing P
,^Z with Smuon 70110)ofDlvlYon3ofBeaaa Pmfetlnm coda.and myrmnm ie REPLACE WATER HEATER P�8
5���< Deml fo antic Con r lA�e®
Linen s y ' v
—xRcHITrSCs= A O
lr. "Normal pubilwarda JUN1 0 2003
30 Licensed Pr�fcu'idn WN BUI 6R DEC
OW NER-BUILDER DECLARATION p
.�or
I hereby affirm Nn I am exempt from to Contrane".License law far the UIL DIIy D'
HI fallowing rcesa..(swoon 701.5,Business and Professions Cour:Any city or county
a�$ which requires a permit to emesum ct,alter,improw,dmmolts6.or repair my structum
fit„^ prior or its issuance.elw requires the applicant for such permit to file a signed mNmcnl Lytton
< that he is licensed pursuant to the provisions of the Comment's License law(Chapter9 Sq.Ft.Floor Area
�0 (commencing with Section 7000)of Division 3 nfthe Buslnesut Professions Code)or
chat he Isexempt d amm both fraand the bfor me alleged emmption.Any violadon of
Section 7031.5 by arty applicant for a permit subjects the app0eml lm a Civil Penalty of 3 VMMeru U Occupancy Type
.at mere tom fin hundred dollen($500).
❑I.uowmrof Nepmpeny,mmy=ploymwiNmsumtktrmlecmmpemdon. 502
will do me wmk,md Nemuqute is rmtimmulad Or offered Tmsale(Sm.7044,Business ppcored n$ eCt10DS
and pmrasdom Code:The Commuter's LiRve law does ret apply m an Owner of 506 — GAS TE P
progeny who bullae mfnmvn Nerma,and who doeuuch work himselfarthrough his 'SOI — FINAL PLUMBING
own emplayeeg,provided matsuch improvements are not Intended m Offered male.IL
hews.,the building or Improvement is gold within rete yeer of completion,the owner- .
bullae,will have the bard.of proving that he did Ila!build or Improve for purpose of
rale.). _
(D I..comm,of the property,am eaeludvely contracting with licensed commitment to
construct Ne Project(Sec.7044,Business and profession Code:)The Contractor's Ll-
mnsn law dins not apply to an owner of progeny,who builds Or improv memon.and,
who contracts for such projects with a canluctor(s)licensed pursuant in doe Commamor's
License Law.
t]I.Creator under Sac. .B At P C for Nis mason
dI/I v A C S Al/Yif. _ Da
I
ORK CO SA OECLARATVI
hereby,dRan under penalty of perjury oro of the following declarmons:
❑I have and will mainmina Cenlriamof Comnnouif-InsumfmWorkmaCompen-
.aon,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,a required by Section
3700 of the labor Cagle,for the performance of the work fm which this permit Is Issued.
My Workefa Pen don{adauspata caroler and Policy number.:
'I s'r/ e policy No.. ��
CERTIFICATE OF E%EMPf10N F7gD r ORKERS
COMPFNSATION INSURANCE
!Glu recti.need not be completed lithe permit is fmone hundred doll.(SIM)
or lege)
1 comfy mel in the omfamam.of the work for which this permit is issued,l shall not
employ any person in my manner an as to become subject o the Workcn'Compensation
Laws of calif gni..Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cemnam of Eacmption,you should
become subject m the Worker's Compensation previsions of me labor Code,you muss
Ofarrhwoh Comply vim such provisions ar this permit 0.11 M deemed invoked.
ry CONSRUCf10N LENDING AGENCY '
'[r (hereby air..doer Nero its Construction lendinpgenry far the performance of
ai s7 the work fur which suis permit(,!grand(Sec.3097,Civ.C.)
(1.7 Q Lendce,Name
z Lender's Adder..
U 0 I cenify that 1 have read this application and shoe mal the above information H
E' cornet.l ageme In comply with all City and county ordinmees and sate laws misting in
Q U building construction,and hereby mthome opmsenmiv Ofthis city to enter upon the
u7 One-mentioned propcny,for inspection purposes.
LL (We)agree to save.indemnify and keep harmless the City of Cupertino against
fA Ilabllhosjudgments.cosu and C.Muu which may In anyway we=against cold City
U Z in concegmace of the Sterling of this Permh.
�--� APPLICANT UNDERSTANDS AND WILL COMPLY WfrH ALL NrON.YPOINT Issued by: Date
SOURCERE TIONS.In
14 []_
C�� Re-roofs
S etumo ApplietwConmactor am
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle oavamous material
IM.rtic,?
defined by me Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Otic,Section 25532(.)? All roofs shall be inspected nor to an roofing material beim Installed.
E]yon �NO P P Y 8 8
Will the applicant or fume building occupant um equipment or dev.. which If a roof is installed without first obtaining an inspection,I agree to remove
it h"'a air cont.in u dc0md by me Bay Aro Air Quality Mmegcmcm all new materials for inspection.
❑Yes NuLowe mad theh 7afdrlaamamrialsrequirementsunderChapmr6.95oftheCalifor.
aHc.1%&5afoiyCode.S,.6.25505,25533.d25534,1undcnnndmmiftie building
es not currently haw a anmL du it' mymspmulhililymnodly occupant of me
mr�`nzo,hmuRbemet r � cab Ccrtifica r Signature of Applicant Date
q 6�" 4 u �1 All roof coverings to be Class"B"or better
Owner or authorized agent Dae
{
CITY OF CUPERTINO
WATER HEATER %► `
CUPERTINO PERMIT APPLICATION FORM
APN# 5/o2 5D d Date
Building Address: So �S�1
#d 75 T/l-ec. I�
Owner's Name: p J Phone #:
Contractor n PhoD ne: d�a S License#:6/a_
Contact: (�/ Phone: 0 1 Cupertino Business License#:
S
Building Permit Info:
Bldg ❑ Elect ❑ Plumb4 Mech ❑
Job Description:
Residential'Al Commercial ❑
A/
Cost of Project: M
• Strapped LJ On Platform El Bonded
New Location ❑ Re lacemenm_
Qty. i
Appli4aVlj Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING