05090147 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT ��CONTRACTQRANFORMA.'TIO _
BUILDING ADDRESS: WATER HEATERS ONLY PERMITNO.05090147
1021 TUSCANY
W NEWS NAME: PERMIT ISSUE DATE
ARDITH WEST 970 E. MAIN ST 09/21/2005
NE: SANITARY NO. CONTROL NO.
(800) 835-5946
ARCHITEC,ENGINEER: �j T BUILDING PERMIT INFO
Gj I p7 BLDG EO PLO MECH
wimSaaoniawiafov'siaaiLICENSED��euaressmiln�onccodde,e�umayl�enlii JobDescrhS DECLARATION `ipHon'� t�
I.fell face ond� (. REPLACE WATER HEATER �r�gyO}/�'
Lmenu Clnt Lic.a , �: c
[ n �oO7
� Date ARCH n
e7 � IunderwnJ my plan alWl he used As public recarN �)�
Licensed Professional Uf/1 n�``+a
OWNEm axe DER DECLARATION f'f a�
90 I hereby a(frm on I am exempt from the Contractor's License Law for the \\��/5:7
O o following rens..(Suction 703 1.5, t,Business and Professions Code:Any coy or county
$ which uquima•Permit re cnntwa suer,improve,demolish,or repair my atrmlare $1000
pd.mits issuance.also ntto ft the
ovisioso Its such ractor aBle a MLacd wlemem
Wal heulicemed pSeoanl come of Division
of duce Business
iUmnselawsCode)9 Sq.Ft. Floor Area Valuation
y SFS 10he is exemptng mfmction 10 00)the
buts ran.(the B ed axe and exemption.
W Cade)m
3.- Wel he b exempt Wert(rom and the bath fm We alleged tumpllon.Any vlolatlone(
Section 7051.5 by any applium lots permit subjects the applicant o a civil penalty of 3 KdAger U u Occupancy Type
nal mots than five hundred dollars(5300).
DI.uownerofdu:property,errmymnploymwildwgeauWkroleeompe Oon.
will&mewarksnd theswmure bnminunded oralfeud mrnm(Sm.7044,Business Required Inspections
and Propensities Code:The Cortisone,Licean Law don ext apply a n e ns owner of q P
property who Wild.or im prnvet thereon,end whodoes such work himself or through his
own employees,provided that such improvemnts art not intended or oaertd for We,If,
however,the building or improvement it mid within on year of completion,the owner.
builder will love the burden of proving that he did let Wild or improve for purpose of
Ask).
❑1,an owner of We property,am exclusively contracting with licensed conuacmn m
construct the project(Sec.7014,Business and Prof nniona Cade:)The Cmtnemh U.
cause Law don not apply be an owner of propeny who builds or Improves merton,cod,
who conuacu fursuch projects with a canuacmr(U Immune!Pool an the Contractors
License law.
❑lamaemptunder See .B&PCfarth4uuan
13700
eer Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury next of me following declaadmu: ,
1 have and will maintain a CeNram of Consent to self-Insure for WorkersCompcn-
on,a provided for by Section 5700 of the Labra Code,for W performance of W
rk for which this permit it lssmd.
I hove and will maintain Wmlmr s Compensation Insursta,u required by Section
of the labor Code,for tins performance of me work far which this permit it issued.
Wakers Coum�pew/t(ion Insunrwe artier nd Policy moves,are:
rtier. a�.s �r s-�• Policy No.:A s—r-'+'543-0
TIP7CATE OF EKE mote PROM WORKERS'
COMPENSATION INSURANCE
(This uNm need not becompleted Iflhe permit 4 forom hunduddollua(SIM)
or less.)
L cattify that In the performance of me work for which this permit is intend.I Iholl net
employ any person in coy mnmr an As he become Mbjem to the Worken'Compemadon
Laws of California.Data
Applicam
NOTICE TO APPLICANT:IL after m W ng this Ccrtifcam of Exemption,you should
become object an the Workers Compensation provisions of the Lahr Code,you must
0 O forthwith comply with such provislans or this Permit mall be abnormal uvnkrd.
y CONSTRUCTION LENDING AGENCY
(••i I hereby rm that them Is a constructioncoconstruction lending Agency rat the performance of
ai � the affi
work ran which Ods perinit Is Issued(Sec.5097,Civ,C.)
GQ Lenders Name
r7 z Landers Address
U Q I certify that I have amid ins pplication and wen that the above Information Is
11, correct.correctrepresentativesect.I agree to comply with all city and county uNinsues and same laws raining u
QE building construction, d hereby nthods,representatives of this city w enter upon me
W abom-mentioned property for inspmorse purposes.
fF gyp (We)agma an nue,Indemnify and keep honnlru 0u City of Cupertino against
(/) liabilities,judgments.cow and expenses which may in coy way accrue Against old City
O`1 In
'once
m of me gmn Ing a permit.
F7 APPLIC UNpS A Oc WI OMPIY WITH Aly ON-POINT Issued by: Date 17- 2- ( --or
S R S
X C -5 Re-roofs J
Signature of ApplicnuConutmm Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Bre applicant ser f num building occupant sore or hotWlc Mnrdom material
As defined by me Cupertino Municipal Code.Chapter 9.11.and the Health and Safely
Section 255320)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes 19a1n�
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It han,dom air contaminants a defend by the Bay Area Air Quality Management all new materials for inspection.
Undo? /�
❑Yes QRS
I have real the huardmsnlwsalsuquiumenu under Chapter 6.95 of the Cantor.
nnixL
Hut"Safety Cade,Sections 15505.15555 and 25531.1 undersand thsifde building
dean not currently have a consul.that it is my responsibility in notify the 0.Tupn1 of the
requirements which sat bcmeipdaru unroof. erureszor Ocnpney Signature of Applicant Date
Owners .41has, Dare All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
Ja10 Fax(408)777-3333
UPEI(TINO
Building De artment
JOB ADDRESS: la-7-1 Tom' �L PERMTT(9S J 90 1 47
OWNER'S NAME: PHONE # _ S
GENERAL CONTRACTOR: a FAX #
I am not using any subcontractors: A)621- tyea;&o
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
J Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO 0 S-7i
WATER HEATER /
CUPEII;TINO PERMIT APPLICATION FORM
APN# 3 Zr `, Date: p/Z0 10 :5-
Building
oSBuilding Address: /O 2— n/
n .� p
Owner's Name: Phone#: q � 3
S
Contractor: ne: License#: 3 *�4S .7 3
Contact: 5 l ' Phone: , Cupertin Busine$s License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential i"— Commercial ❑
Cost of Project:
Strapped El On Platform ❑ Bonded ❑
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
1 PPERMITFEE Plumbing Permit Issuance PLUMBING
1 BENERGY Energy BUILDING
BUSLIC Business License BUILDING