07010116 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �1�']CRAC OR � �
PERMIT NO.
BUILDING ADDRESS:
PERMIT LSSUE DATE
OWNER'S NAME:
CHERYL ALLEY 24707 SAN FERNANDO RD 01/19/2007
SANITARY NO. CONTROL NO.
3NE:
(661) 259-7131
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
J00O LICENSED CONTRACTOR'S DECLARATION Job Description
e ty I hereby affirm that I am licensed under provisions of Chapter 9(commencing
4 i UJ with Section 7000)of Division 3 of the Business and Professions Code,and my license is REPLACE WATER HEATER
a„ in full force and effect/ b Lhc# (.4 3 7 0
j ? License Class l.�
-a Date Contractor
ARCHITECTS DECLARAT N
C-111 understand my plans shall be used as public records
�y
LLo in Licensed Professional
OWNER-BUILDER DECLARATION
n�N I hereby affirm that 1 am exempt from the Contractor's License Law for the
no 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
y' prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
-?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $1200
YF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y 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 3 6 212 0 C 5 . Number Occupancy Type
not more than rive hundred dollars(5500).
0 I,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 are 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.).
0 I,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 Law 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 Law.
0I
am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 I have and will maintain a Certificate of Consent to self-insure for Workers Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
�I 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 nu ber are:
Cartier. )k Q- -I'MIr h Policy No.:�'A )
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workcr s Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z— CONSTRUCTION LENDING AGENCY
Fr►CA-� I hereby affirm that there is a construction lending agency for the performance of
a+> the work for which this permit is issued(Sec.3097,Civ.C.)
LLl A
Lender's Name
z Lender's Address
U Q 1 certify that I have read this application and state that the above information is
LL ►" correct.I agree to comply with all city and county ordinances and state laws relating to
O Ubuilding construction,and hereby authorise representatives of this city to enter upon the
U about-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
o..4 liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
�+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued t y:
SOURCE REGULATIO4.
=,---� 117 Re-roof;
Signature of Appli Contractor DateType of Roof
HAZARDOUS MATERIALS DISCLOSURE
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 Tool s shall be inspected prior to any roofing material being installed.
0 Yes
If a zoo is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Yes Cu r�tf q /J
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&SafctyCodc,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
requirements which must be et prior issuance of a Certificate of Occupancy. ) Signatu-e of licant Date
6&r_ 1 - /'/- y All roof coverings to be Class"B" or better
Owner or authorizeda6ent Data
Community Development
10300 Torre Avenue
'. Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
CUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
?a-� kp teM�oe.r (-'-+' -
OWNER'S NAME: Ck p-l(9-q PHONE # -tvk-a5?- &kO5
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and coni lete 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
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
WATER HEATER
OF
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
1 ��-�1.Q ren h�r �i 1- Phone#:
Owner's Name: C
Contractor: Phone: (,-(e( License#:
c -
6W0-e ale �aTe�s a b ' 3 )
Cupertino Business License#:a �
Contact: Phone: (�b I p
cow Li-T 1 e,(' e a4-51- 0540
Building Permit Info:
Bldg ❑ Elect ❑ Plumb d Mech ❑
Job Description:
Residential Ed Commercial [;
� Uee S�, „o c ,� ScAn,e I oCgT�'Dv�
Cost of Project:
Strapped On Platform Bonder i ❑
New Location ❑ Re lacement
Qty. if Fee Group
Applicable Fee ID Fee Description
BpWHEAID Water Heater/Vent BUILDING
PpE�TTTEE PlumbingPermit Issuance PLUMBING
ENERGY Ener BUILDING
USLICB
BENER Business License BUILDING