07050248 CITY OF CUPERTINO
BUILDING EgVISICIN PERMIT � TI N*
PERMIT NO.
sUIUlING,4�pqhAFT DR AFFORDABLE WATER HEATERS & 07050248
OWNER'S NAME: C PERMIT ISSUE DATE
HETZ ROBERT F 24707 SAN F'ERNANDO RD 05/24/2007
NE: (661) 259-7:.31 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Ica LICENSED CONTRACTOR'S DECLARATION Job Description
j V 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing REPLACE 5 0 GAL ELECTRIC WATER HEATER/GARAGE
:Z with Section 7000)of Division 3 of the Business and Professions Codc,and my license is
y in full force and effect
j v�Z License Class Lic.A
E tp Date Contractor
ARCHITECTS DECLARATION
i a a 1 understand my plans shall he used as public records
)yt.l
'
U. Licensed Professional
y
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
:00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
e 0 which requires a permit to construct,alter,improve,demolish,or repair any structure
z y prior to its issuance,also requires the applicant for such permit to rile a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.FI.Floor Area $1300 Valuation
r t= (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 37502036 11 Number Occupancy Type
not more than rive hundred dollars(SSW).
Q 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 We(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q P
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.).
Q 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense taw 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
LicenseLaw.
Q lam
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:
LJ I have and will maintain a Certificate of Consent to self-insum 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.
PI 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'sCompensation_JU Insurance carrier and Policy nyLptbe arc( \
Carrier. Policy No.: LWI b �UY
CERTIFICATE OF EXEMPTION FROM WORKERS'
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.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 Worker'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
E-r►�-+ I hereby affirm that there is a construction lending agency for the performance of
p4> the work for which this permit is issued(See.3097,Civ.C.)
WCh A Lender's Name
z Lender's Address
U Q I certify that I have read this application and state that the above information is
r— correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction.and hereby authorise representatives of this city to enter upon the ^\
a shove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
tom- v) liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
r"^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date �r 2
SOURCE REGULATIONS. p
�I U1xr'�- Re-roofs
Signature of Applicant/Contract Date
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
Cote,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Q Yu [�lo
Will the applicant or future building occupant use equipment or devices which If a roof is instz fled without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materia',s for inspection.
District?
Q Yes I%qo
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Codc,Sections 25505,25533 and 25534.1 understand that iC the building
docs not currently have a tenant that it is my responsibility to notify the occupant of the
requirements which mel poossuancc of a ertificatc mrOcempncy. Signa e of Applicant Date
✓
TZI "0�7All roof coverings to be Class'B"or better
Owner or authori gent Date
CITY OF CUPERTINO
WATER BEATER 0
CUPEf�TINO PERMIT APPLICIATION FORM
APN# Date: S,
r3
Building Address:
100 h ) C.rck(t Pf .
Owner's Name: Phone#:
0 0�ner+ (ACT-7- tog,- As-'1 -
Contractor: Phone: (r Ce i License#:
ab e ale �c,Tr�s a -713 I t��7 3108
Contact: Phone: b i q Cupertino Business License#:
co
Building Permit Info:
Bldg ❑ Elect Ptzmb Mech
Job Description:
Residential Commercial ❑
pp-PlCkee Sv Ilo (:tQC. �1'E'f SAme 10 r-c,,-rl*br\
Cost of Project: 1 3 r
Strapped On Platform Bonded Er
New Location ❑ Replacement
Qty. if
A licable Fee ID Fee Description Fee Group
BPWHEATER Wa ter Heater/Vent BUILDING
PPERWTFEE Plumbing Permit Issuance PLUMBING
BENERGY En;r BUILDING
BUSLIC Business License BUILDING
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
dool — Fax(408)777-3333
f'UPEkTINO
Buildin r Department
JOB ADDRESS: PERMITS
L(/%
OWNER'S NAME: p h err P- PHONE # (40k-,>51- k eS"-?
GENERAL CONTRACTOR: FAX# 771
I am not using any subcontractors: Qf 57-,,t Y-Lr�
Signature Date
Please check applicable subcontractors and com lett!the following information
60 SUBCONTRACTOR BUSINE&5 S 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
7
er/Contractor Signature Date
Community Development
r " 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
CITY OF
':UPEkTIN0
Bui l:n r D e artment
JOB ADDRESS:
S: PERMIT
f0 2 C rc-ei i�r% 6Z3
OWNER'S NAME: if ('GPtrNl 01C -C- HONE # g K44 ape) ('-j
GENERAL CONTRACTOR: ( AX # K9
I am not using any subcontra tors:
Signature Date
Please check applicable subcontractors and com 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 JJ
{,- Owner/Contractor ignature Date