07010038CITY OF CUPERTINO
I1�TERMTTQN•
BUILDING DIVISION PERMIT
T.
BUILDING ADDRESS:
PERMIT NO.
21914 GRANADA AV
AAA FUF
-
PERMIT LSSUE DATE
OWNER'S NAME:
JANICE LU
nnAT3-rM7 NKTTrTn
1712 TONE AVE
01/05/2007
SANITARY NO. CONTROL NO.
'NE:
(408)2S3-4717
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MEC14
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
REPLACE WATER HEATER
in full force and t
License Class Lic. i
Dam Contractor
Ci
71
A CHITECTS DELLA ON
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
! prior to its issuance, also requires the applicant for such permit to rule a signed statement
Sq Ft. Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
$1300
13 0 0
(commencing with Section 7000) 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
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
357161--7 Number Occupancy Type
not more than five hundred dollars (5500).
.
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
Required Inspections
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements ate not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense raw does not apply to an owner of property who builds or improves thereon, and,
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Caw.
❑ 1 am exempt under Sea . B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, 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, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
Cartier
C TIFICATE OF EXEMPTION FRO. WORKERS'
CCC
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less)
I certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workcrs' Compensation
Laws of California. Date -
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the labor Code, you must
i~ forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
.n. 1 hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued (Sec. 3097, Civ. C.)
~ Lender's Name
a
L.cm ices Address
1 certify that I have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating to
Jbuilding construction, and hereby authorim representatives of this city to enter upon the
above-mentioned property for inspection purposes -
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments. costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
qf(0�(�a
2 Date
�- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by:
SOU E TIONS.
Re -roof:;
S niturc orApplicanf/Cogfractor Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes �Np
If a rool is installed without first obtaining an inspection, I agree to remove
Will the applicant Ar future building occupant use equipment or devices which
Mil. hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑ Yes No
have read the hazy tws materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
'
req ments which must be reel prior to issuance of a Certificate of Occuparict.
Applicant Date
Sinatul e of plicant
��
,
g
All roof coverings to be Class "B" or better
ownersaarixcdant 41, Date "
CITY OF
-,UPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
PERMIT #
')-7D l Z1� "3rd
OWNER'S NAME:
PHONE # - d >76
GENERAL CONTRACTOR:
FAX #
/„ Q� -0?
I am not using any subcontractors: �` �
Signafure Date
Plea. -;e check applicable subcontractors and conivlete the following information:
Owner/ Contractor Signature
Date
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
Tile
Owner/ Contractor Signature
Date
CITY OF
CUPEf�TINO
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
/or] o 1 003 6
APN #
Water Heater /Vent
Plumbing Permit Issuance
Ener
Business License
Date:
Building Address:
Phone #:
Owner's Name:
Contractor:
Phony;:
License #:
Phone;:
Cupertino Business License #:
Cont t:
Buildingermit Info:
Bldg ❑
Elect Plumb
Mech 0'
Job Description:
Residential;
Commercial ❑
Cost of Project:
P
Strapped ❑ On
latform a Bonded
❑
ff-
New Location
Replacement
Qty. if
Fee Descrition
Fee Group
A licable 1 -lee
BPWHEATER
PPERMITFEE
ENERGY
BENER
USLICB
Water Heater /Vent
Plumbing Permit Issuance
Ener
Business License
BUILDING
PLUMBING
BUILDING
BUILDING