04020056 (2) ' CITY OF CUPERTINO � •ay^ +
BUILDING DIVISION PERMIT CONTRA T0RJNJ'URUTJON- -
BUILDINGADDRESS: WATER HEATERS ONLY PERMRNoh4020056
OWNER'S NAME: PERMR ISSUE DAM
CHARLES MTT.T.P.R 970 F MAIN ST, SUITE 200—
)NE: SANITARY O. C NTROL NO.
(800) 83S-S94l;
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 o I�
Op LICENSED CONTRACTOR'S DECLARATION
b F 1 thereby affirm that I am licensed under previsions of Chapter 9(commencing Iib DOSCrIptlOn
aa wife Section 7000)of Division 3ofthe Business and Professions Code.and my license is
^< iafell In eandeffe 7 W57 3 pp�� pp
iq�yz
Lice la's 36 c 3 REPLACE WATER HEATER F'�Vbi+ LSO
Dow�y$ I undersand my If
ARCH S,D M11t 1 f FEB 1 9 2004
3 c Licenud Pmfcaaionel
OWNER-BUILDER DECLARATION WBUILDING
a masa
I .(Sere that 1 exempt from fee Contractors License Law for the
0 0 fallowing reason.(Section 71131.1.3,Business and Professions Calc:Any easy or county
t4u which requires n permit re quires W L ohm,improve,demolish.ri e pair any immune
ment
)dor m its i licensed
pursuant Neo n to We provision nt of We
men Contrc tui s Limicnim Law statement
l
SC that he momm nangsedtion7 N)ofDiviomofNcCo Business
sinessLimnuiaw(C Code)or Sq.Ft.Floor Area Valua[on
t$ thamwlns exempth Section 70000 th( basis n 3for of the egad esaandmpt Professions vi Cade)or
3 11ut he u cramps IMmfrom and the buts for fee alleged csempGon.Any viob0on of
Section 7031.5 by any applicant for a permit subjects We applicant to a civil penalty of -3�elo o OQGD araC Type
not mom than five hundred dollars(5300). P y yP
04vownerofthepmpeny,mmyemploy wifewagessssheirsolecompevmion,
will do Nework.and feemoUstan is not intended or.Mmd foraats(Sec.7044,Business
and Profession'Cadc:The Conuacwn's License Law does WI apply m an owner of Required Inspections
property who bonds;or improves thmean.and wha does such work himself or through his
own employees,provided thats.h improvementsare maintained mortared for sale.If,
however,the building or Improvement ii wifein one year of completion,the owner.
builder will have We burden of proving that he did not Wild or improve for purpose of
sale.).
❑h as owner of the property,am exclusively commollog with licensed contractors to
construct%e prefect(sec.7044,Business and Professions Cade:)The Contractor's U.
cove Law does not apply to an owner of property who Wilds or improves famous,end,
who contracts for such projects with acortrsmr(s)licensed prandand to We Contractor's
License Law.
❑1 am exempt under Sec. .B&P C for thus reason
Owner Gae
WORKERS COMPENSATION DECLARATION
I Wmaffirm by am under penalty of perjury nae of the following declaralimer
1 hive and will maimsin a Certificate of Consent m self-Insure for Work,.
u provided for by Section 3700 of do Labor Code.for the Performance of We
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of fee labor Code.for the performance of We work for which this permit is issued.
My Worker's G`om sa0an nsurance eamer and Policy nymber are:
Cartier. J' � Polity Nd y S Vy
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thacection need nothecomplemd Hthe Permit is formic hundred dollam(Sip)
or less)
I certify that In We performance of the work for which this permit a issued,I shall not
employ any person in any summer so as a become subject to We Workers'Compensation
Laws of California.Date
Artificial
NOTICE TO APPLICANT,If.aper making this Certificate of Exemption,you should
become subject in the Workers Compensation previsions of We Labor Coda.you must
OfoMwith comply with such provision or this permit shall W deemed revoked.
z^' CONSTRUCTION LENDING AGENCY
I hereby affirm that then is a construction lending agency for We performance of
L�
We work for which this permit is issued(Sec.3097,ON.C.)
WQ Lenders Name
�
]z Lenders Address
U Q 1 certify that I have mad this application and sate that da above information is
E-t correct,I tai ce in comply with all city and county entrances and sate laws relating to
0 building construction,and hereby authoim represenalives of this city to enter upon toj7c�a
W above-mucdproperty for impaction purposes.
y (We)agree m saw:,indemnify and keep harmless the City of Cupcnino against
w.t h liabilities,jsjudgdgmenu.cora and expenses which may In any way seems against said City
U 7 in conuquenc of Ne griming of perm.. Da
F7 APPLICA NDER, N D W7 OMPLY WITH ALL
/NON-POINT Issued by:
50 RC L S. C "�r"a"i
Re-roofs
HAZARDOUS
Signature of ApplicaDem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the apPlicanl no fMun building occultist.Chrerre or handle Health us materisi
as tlefincd by Nc Cupertino Municipal Cade.Chepar 9.13.and tiw.NcaIN and Safety
ale,season%33(eh All roofs shall be inspected prior to any roofing material being installed.
❑Yes U;3
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
7DW,ict?
t harannus air ronaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
❑YesI have mad the havnnusmaarialsrequiremcna underChapar6.95 oftis,Califor.
Health a SafctyCode,Secants35505,25533 and 35534.iundersand i atifNe Wilding
s not currently ham a'nam that it is my reapovhility m oddly the...pant of Ne
iremcn which must Wme 'or in San co IsCcmflcaaofOccu ryry. Signature of Applicant Date
2 5 b All roof coverings to be Class "B"or better
Dam
CITY OF CUPERTINO r
- J WATER HEATER
CUPER,TINO PERMIT APPLICATION FORM
APN# Date: /
-?,PD l,S� �5l o cf
Building Address:
G/zF
Owner's Name;(�, j/
�S 3 Phone#:
-72L/ 7
Contractor, 0 License#:
3 - SFS 3
7
Contact: Phppgge#:
aJ PO d r3 5
Applic ant/Gew4aeter:
• - t�'/3• 4vynzf. i a> S q1-/23 z
Building Permit Info:
Bld Elect lumb Mech
Job Descri tion:
esidential• �(.iJ Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation: od
. lTJoo
Type of Construction: Occupancy Group:
Qty. if
Applicable Fee ID Fee Description Fee Group
/ BENERGY Energy BUILDING
BPWHEATER Water Heater/Vent BUILDING
/ PPERMrrFEE Plumbing Permit Issuance PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BMrl'IGAT Housing Mitigation Fee BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG