04100127 (2) n CITY OF CUPERTINO '°' a�
BUILDING DIVISIONPERMIT C0NTRAC1nR INF®RMATI0N5 <;
BUILDING ADDRESS: ALL VALLEY PLUMBING PERMIT N1041O 0127
21725 TERRACE DR
OWNER'S NAME: PERMIT ISSUE DATE
BILL MCCARTY 170 BRANNON DR 10/19/2004
]ONE: SANITARY NO. CONTROL NO.
(510) 376-4816
ARCHITE (ENGINEER: BUILDING PERMITIN120
BLDG ELECT PLUMB MECH
0 0 0 0
yO0 LICENSED CONTRACTOR'S DECLARATION
m❑ I hereby affirm that I am limnsed unJ sof Chapter 9(commencing Job Description
W with onion](KNt)nf Division3of the Buxi and Profcssinm Code.and myliccnsc is
ter cean «e t. �$ REPLACE WATER HEATER 15 F!5(
j qLic nsc Clms Lic.M r �L E
ng7 Dam Contract Y
QQ ARCHI3ELT5 DECLARATION
d< 1 understand my plansahall he mod as public menrds
;LLEW U nCT LID 1004
Licensed Pntfcseionel
�p5 OWNER-BUILDER DECLARATION
E0 S I botchy affirm that 11. exempt from the Continuum's Co LiAnyc Law for the
E00 o fallowing massa.Section]1151.5,Business and are,de ism Calc:Any city or manly
K$ which requires a pesmir m construct,eller,improve,demolish,or repay any structure $750
sa-zi
our to its issuance,also motiires tlsapplicam far such remit of file if alpnednammem
< that he is licensed pursuanusthe previsions ofthe Contractors LicenseLaw(Chapter 9 Sq. Ft. Floor Area n
or (antimatter,with Section 7")of Division 3 nf,hO Business and Pmfcexinns Code)or
m5 that he is exempt thnarmm and the basis for the alleged exemption.Any violation of
Section]031.5 by any applicant for a permit subjects the applicant a civil penalty of
not mom than rive hundred dollars($500). e Occupancy Type
❑ 1,as owner of the property,or my employees with wages as their sale compensation,
will do the work,and Ne structure is not intended or offered far sale(Sec.7W,Business
and Professions Code:The Contractor's License Lew does and apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements arc nal intended increased formic.If.
however,the building or impmremenl is sold within one year of completion,Ne owner
builder will have the burden or proving Nn ee did not Wild or improve for puryose of
sale.).
❑1.as Owner of the property,em exclusively contracting with licensed convenors Is
consuucl the project(Sec.7044,Business and Professions Cale)The Convactori Li.
cense Law dues not apply to an owner of properly who Wilds or improves Hereon,and
who contracts for such projects with a cnntranor(s)licensed pursuant o the Contractor's
License Law.
O 1 am exempt under Sec. B&P C for moon
Owner Data
WORKER'S COMPENSATION DECLARATION
7C337'7,'W
1 hereby affirm under penally of perjury one of the following declarations:
I now and will maintain a Certificate of Consent to self-insure,for Worker's Compen-
tion,as provided for by Section 3]00 of the Labor Code,for the p r o r ance of the
rk for which this pa'mtil is issued.
1 have and will maintain Worker's Compensation Insurance,u required by Section
of the Libor Code,for the performance of the work for which this Permit is issued.
y Worw,',Compemat]on Insurance carrier and Policy bar art: 'rtie\: EXEMPTION Policy Na: L�
/L—�C6RTI��CFI OMR( SATIONFROMWORKERS'
COMRENSATION INSURANCE
(This seninn need dol M completed five permit is format hundred cullars(SKXB
to Ica,.)
I century that in the performance of me work for which this Permit is issued.1 shall not
employ any person in any manner an a to become subject to Lou Worken'Compensation
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 M the labor Cndc,you mus
.J O forthwith comply with such provisions or this Permit shall he deemed invoked.
Z '-' CONSTRUCTION LENDING AGENCY
-�-+� I hereby affirm that there is a comlrvetom lending agency lar the perfurmmce of
7r Ne work for which this permit is issued(Sec.3097,Civ,C.)
W Q Lendcr'a Name
= 2 Lender's Address
fJ Q 1 certify Net I have reed this city
and coon and harc Nal the shout iws n l addit is
W t" building I agree to Comply With all city and county outivas or and ewm lewd relating e
Q V albovengconsnedpro and hereby amhonp repruenulirrs of this city to enter upon the
W shove-(We)agree
to saw.
for inspection an keep es.
(We,)agree Its save,indemnify and kith harmless the City Of rac against
against
`U Z judgments.of the
mis and expenses thisPe mit. may in any way accuse against mid Llly
V z A APPLICANT
UNDERSTng ANDS
this permit. /
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 1
SOU RC EGULATI /
1n �L Re-roofs
Sig re of Applic onham Dale
HAZARDO ATERIALS DISCLOSURE Type of Roof
Will the applicant or future building OccuPanl store or handle hvarJuus material
as dtOned by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safely
CoJc, Iu1 Sc❑cV n 25532()7
or All roofs shall be inspected prior to any rooting material being installed.
Will the applicanm building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit havardio s air contaminants as defined by the Bay Area Air Quality Management all new materials for Inspection.
Diavicr?
Yes
I have mad the hay duns materials requirements under Chapter 6.95 of NC Califon
nig licahh&Safciy Clale.Secuans 255()5,25533 and 25534.1 undersand mal if thc building
urea not currently hum a mnatiL that it is my responsibility it,notify r uecupant of the
requirements which muatbe0 , dratissuaneeof.CafL muNnag Signature of Applicant Date
u- 4 Dq
Owner orauthorimJ Data g All roof coverings to be Class "B"or better
�"-
Community Development
aClOF
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS:
jjPjH0NE #5T) -"- 1
E # X41 00 1o�`7
OWNER'S NAME: 13i �� MG Al2 GENERAL CONTRACTOR: 1\ \/A 12 P #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followin information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
is Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
10 - 1q -
er/Contrac ignature Date
CITY OF CUPERTINO 27
WATER HEATER D
CUPERTINO PERMIT APPLICATION FORM
APN# 3 5 �o 1-I - O 12 Date: 1 0 _ SCI — 0
Building Address:
Owner's Name: t 1\ MG A2�c Phone#:
4DS - a53 -aloS
Contractor: Phone: License#:
At\ �A 11 171 Urn j r\.G c3to 7C(,A q C5
Contact: q ytv, Phone: Cupertino Business License#:
SAnd sld - �,c� ] Go�i5 Z3 C>
Building Permit Info:
Bld Elect ❑ Plumb A Mech ❑
Job ascription: l `_
Residential ❑ Commercial ❑
Cost of Proje t
`l5 b °
Strapped El On Platform El Bonded El
New Location ❑ Replacement ❑
ty. if
icable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMTTFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING