08100110 CITY OF CUPERTINO ?+` PagSv
BUILDING DIVISION PERMIT , CO1�fTR?iJORINk',UT.t1 TA Osl' ,`, '
BUILDING ADDRESS: PERMIT NO.
10178 CASS PL TBD - TO BE DETERMINED 08100110
NER'S NAME: PERM]'ISSUE DATE
ALICE LEE 10/17/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMITINFO
REPLACE 50 GAL WATER HEATER eO EO PLO O
u00 LICENSED CONTRAMRS DECLARATION I Job Description
m I hawby affirm that 1 arts Iicemed under pmvin of Chapwr 9(Commencing P
U with Smden70fat. D.Y.. 3ofthe Basinaasat ftf si=Cde.admylieeaseis
^ y in full tome and effect.
Liceme Class L'm.a
=q DateContractile
eP ARCHfIECTS DECLARATION
Y C< 1 understand my plan.Mall he used u public rtenrm
JyU
s a Licensed Professional
OWNER-BUILDER DECUBATION
1 wrthaR
y rm that 1 am exempt from the Conttanafs License law for the
E O O following mason.(Saction 703 1.5.Business and Professions Code:Any city or County ,
E
mg! which requites a permit m construct.ales.improve,demolish,or rook any suemure
prior b its issuance.also requires the applicanlfor such permit to file a signed stamoroM
£ < thuhslicensedp.ItotMprovisionsoftheContracorsLaaeumlaw(Chapter9 Sq.Ft.Floor Area - Valuation
EF2 (commencing with Section?000)of Division 3 of the Business and Pro2esiom Cude)or
Y� 9 the be is exempt therefrom and the basis fon the allmd exemptions.Any violation of
Sudan 7031.5 by my applimat for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
trot Come thaa five hundred Mian.MOR
0 1,as owner of itis property,or my employes with wages as their sok compem+don.
wiBdothewmk-andtheswnumsnotimm�doaffudfmrale(Sx.' .Bu rens Required Inspections
and Professam Claim The Commoner License Law does not apply use.n owes of q P
properlywho wilds or improves d smarm.and who dosowitwart hivesIfor through hu
own employes.provided that such improvements are not immmded mediated formic.If,
however,the building or Improwmem is said within one year of completion.the owty-
buildm will have the burden of pressing that he did not build or improve for purpose of
sok.).
0 1.as owner of the properly am exclusively contracting with licensed ron==to
Construct the projm(Sec.7014.Business ad Pro(euiom Code:)The Contrxtots U. .
came law does not apply as an owner of progeny who builds or improves themon.ad.
who Contracts fon such Projects with a contractor(s)Ileemed parmam to the Conuxtars
License Law.
Olson uemDt a/radii See Bk PC fee '
ser �,GP.r e J , �.G` D.x /G /7
WORKERS COMPENSA ONI NDECL3RATION
I hereby aRnm under penalty of perjury arc o(the following daluamo r.
❑I haw and will mainsin+Certifimm ofCamenl to self-Infuse In.WmFe/aCumpen-
aadon,as providd far by Section 3700 of the labra Code.far the perfart axace of the
week for which this permit is issud.
0 1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the labor Coast.for the perforon.ofthe work for which this Permit Is issued '
My Workers Compensation Insurance carrier and Policy number+m:
Cartier Policy No.:
CERTIFICATE OF EXEMP]ON MOM WORKERS'
COMPENSATION INSURANCE
(This section need not kcamplemd if the portal s forme hundred dollars($100)
to LMI
I cerdfy that in me performance of the work far which this booth is issued,l"I not
employ anyperso nay manrcrseu mbecome subject m the Warkeri Compensation
Laws of Calif. t
Applimnt � ( Cid n i
NOTICE TO APPLICANT.1f,after in the Cisions o of Exemption,you Mauch
becomeh comp y the Workers Compensation provisions of the labor Cade,you muss
,J 0 forthwith comply with such provisions m mu permit Mill be rimmed revoked.
zi 5; CONSTRUCTION LENDING AGENCY
[-.ate-` I hereby affirm that them s•comractum kndingagen far rite performance of
!Yit7 the wash(tar which this permit k issued(Sec.3097,Civ.C.)
Lu Q Landers Name
0. z Lenders Address
U O 1 mnify that I haw mad this application and start Lord the above information is
W E Comma.I agree m comply with all city and county ordinances and sum laws leasing m
.C) building cooswetion,and hemby aumarim reprexnmives of his city to enter upon the
W .hove-menuoned property for impotami purposes
E~6. (We)agree to taw,indemnify and keep harmless the City of Cupcnino against
CAliabilities,judgmens,coasandexpcmm which may manyway accrue againIIsaid City
U Z in consequence of the graving of this pmout.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date O-
SOUIr REGULATIONS.
l-4��J ': i c_t ! rl Ail�G��� Re-roofs
signet.. Af pplicalutC.mmot r Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will f applicant or future building accuFmL sort or handle bamfdous mammal
dcOned by tho Cupertino Municipal Coda Chapter 9.12,and the Health and Safety
.Smtion zss32(.)7
pYm lytic
.,/ All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future wilding amup+nt use rgmpment or devies which If a roof is installed without firs[obtaining an inspection,I agree to remove
emit m,,ardnus it contaminants as defined by the Bay Art+Air Quality Management all new materials for inspection.
Disuim7
Dy. '�(No
1 have mad me harardexs mamrmissequircmens under Chopur6.95.(the Califor-
niaHmlthhSdcry Cade.Situ m25505.25533ad 25531.1 understand thatifthe building
does not currently haw•mnana mu it is my reopm eihiluy m notify the o copant of the
requimr(pia which muslbe mel ar ttatt�an cmdrmam ar Gecu Signature of Applicant Date
Owneror.h nice.gCm ( Ol nData All roof coverings to be Class'/¢•'or better
r
�D' CITY OF CUPERTINO
WATER HEATER
� OF
CUPERTINO PERMIT APPLICATION FORM
gibo w
APN # Date:
`1 . �U /0 - 17 -0
Building Address:
vv C4
Owner's Name: Phone #:
Contractor: Phone #: yep ,f fi-c-
�C:ZG IC kVV l�v2 Fax #:
Cupertino Business License #: Contractor State License #:
-7
Contact: Phone #: f4 7
Sf?Nl�� L C-041 Fax #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb M Mech ❑
Residential ® Commercial ❑
Job Description:
sG G aL G,14-
Strapped [ c On Platform Bonded []— New Location ❑ Replacement
Valuation (cost of project):
Project Size: Express ❑ Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to
the application or if applicable, include in plan set & the sheet index.
Green Building Points achieved:
Revised 6/16/08
CITY OF CUPERTINO
WATER HEATER
C TY OF
CUPERTINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCWHEATR Commercial Water B PCWHEATR
HeaterNent
1BSEISMICOM Seismic Commercial B
f 1PRWHEATR Residential Water B PRWHEATR
` HeaterNent
f 1BSEISMICRE Seismic Residential B
1PPERMITFEE Plumbing Permit P •
1TRAVDOC Travel & B
Documentation
1BUSLIC Business License B