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09020111 CITY OF CU f�tt hh BUILDING DIVISION PERMIT 14� t � � 3YI� r PERMIT NO. BUILDING ADDRESS: nill 10963N R PERMIT ISSUE DATE OWNER'S NAME: A CONTROL NO. '7 BUILDING PERMIT INFO ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH p LICENSED CONTRACTOR'S DECLARATION Job Description U I hereby affirm that I am licensed under provisions of Chapter 9(commencing Z with Seetion 7000)of Division 3 of the Business and Professions Code,and my license is RPLC 4 0 3AL WATR HTR LO.0 IN GARAG H in full force and effect ? License Class Contractor r Date � ARCHITECTS DECLARATION LL I understand my plans shall be used as public records D 66 ` t; Licensed Professional OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the is a O following reason.(Section 7031.5,Business and Professions Code:Any city or county 4.-9 which requires a permit to construct,alter,improve,demolish,or repair any structure Valuation prior to its issuance,also requires the applicant for such permit to file a signed statement S Ft.Floor Area Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q FS$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 8900 U52 5 2 that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500). 31637017 . 00 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 sate.). 1,as owner of the property.am exclusively contracting with licensed contractors to co wct the project(Sec.7044.Business and Professions Code:)The Contractor s Li- ccnse 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 Contractors License Law' 0 lam B&P C for this reason exe tun Sec Owner Date WORKER'S COM SATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a Certificate of Consent to self-insure for Workces Compen- -ion,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 0 I have and will maintain Workers 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 are: Carrier. Policy No.: 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.1 shall not employ any person in any manner so3s tobccgrneubj_ect orkers'Compensation Laws of California.Date�� 7 ley�I& �— Applicant NOTICE TO APPLICANT:If,after mating this Certificate of Excmpuon.you should become subject to the Worker's Compensation provisions of the Labor Code,you must ,J Z forthwith comply with such provisions or this permit shall be deemed revoked. Z CONSTRUCTION LENDING AGENCY (.�►. I hereby affirm that there is a construction lending agency for the performance of Q! the work for which this permit is issued(Sec.3097,Civ.C.) W A Lender's Name 0Z Lender's Address -- U C) I certify that I have read this application and state that the above information is correct I agree to comply with all city and county ordinances and state laws relating to Vbuilding construction,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes a (We)agree to save,indemnify and keep harmless the City of Cupertino against mE"t fA liabilities,judgments,costs and expenses which may in any way accrue against said City 7 p \ Date U 2 in consequence of the granting of this permit. (_. G r-m APPLICANT UNDERSTANDS AN9 WILLCOMPLY WITH ALL NON-POINT Issued by: SOURCE GU ON b �g D C� Z Re-roof; Sigppliant/Contractor Date nat o AT of Roof HAZARDOUS MATERIALS DISCLOSURE YPe 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. C]Yes ro I agree to re mo If a root is installed without first obtaining an inspection, � _ Will the applicant or future building occupant use equipment or devi devices all new materials for inspection. it hazardous air contaminants as defined by the Bay Area Air Quality Management strict? (]yes [7Y\Nu I havc read the hazardous 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 msponsib'ity to notify the occupant or the Date requirements w ich m met�lo �rjfa �ficalc_ ecopancy. S ignatu-e of Applicant ieant All roof coverings to be Class',V'or better Owner or a rixed agent Date CITY OF CUPERTINO _an WATER HEATER CUPEf�TINO PERMIT APPIJCATION FORM APN # Date: 6 FEBd � Building Address: 0863 No R-T i� r/ E' L 1) C vP k -TI A) Owner's Name: Phone #: you MATZE )� (,yo 0 2_5 5-0 Contractor: Phone #: p �( Fax #: Cupertino Business License #: Contractor State License #: Contact: Phone #: oHD J MA -7 -ZEK (LI08)d55 - 0 / 0 � v Fax #: Building Permit Info: Bldg ❑ Elect ❑ Plumb Mech ❑ Residential Commercial ❑ Job Description: REf>LAeE VGAL W47[ P\ NE�I)TC2 I-&C- A7C)D 14 67XRACiC Strapped ® On Platform Bonded ❑ New Location ❑ Replacement Valuation (cost of project): in 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. IGreen Building Points achieved: Revised 01/07/09 CITY OF CUPERTINO WATER HEATER Of CUPEkTiNO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Permit Type Group 1PCWHEATR Commercial Water B PCWHEATR HeaterNent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission F'ee 1BSEISMICOM Seismic Commercial B 1PRWHEATR Residential Water B PRWHEATR HeaterNent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission 1'ee I 1BSEISMICRE Seismic Residential B 1 PPERMITFEE Plumbing Permit P 1 TRAVDOC Travel & B Documentation 1 BUSLIC Business Lice Ise B Community Development - 10300 Torre Avenue a= Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 C1TY OF rUPEkTINO Buildin De artment JOB ADDRESS: O Q6 '�L+2• PERMIT # c ore R-r r�6 CA C(5. i OWNER'S NAME: ,' 0H 01 A_T F F_t PHONE # 97 GENERAL CONTRACTOR: FAX# I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the followin information: S—jaI UBCONTRACTOR BUSI14ESS 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 ;er/Contractor Signature Date