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CITY OF CUPERTINO
N PERMIT�1��'�•
BUILDING DIVISIO
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BUILDING ADDRESS:
PERMIT NO.
19701 ALDERBROOK WAY
ALL VALLEY PLUMBING
OWNER'S NAME:
PERMIT ISSUE DATE
rON
SA CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMCr INFO
BLDG ELECT PLUMB MECH
REPLACE WATER HEATER
C7 D O D
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
in full force and effect. �- r!� ! fi
License Lic. 0 y
Date Contractor I 1
ARCHITECTS DECLARATION
li I understand my plans shall be used as public records
Licensed Professional
OWNER - BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
i 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
Sq. Ft. Floor Area
Valuation
prior hi its issuance, also requires the applicant for such permit to file a signed statement
9
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
(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
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 (SM.
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
q
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
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.).
❑ 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•
sense 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.
❑ I 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:
❑ I have and will maintain a Certificate of Consent to self -insure for workees 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 Workers ompensafion Insurance carrier and Policy number am: / 2
- p6
Carrier. 1 C-19- ' Policy No.: Cowl 1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for ono hundred dollars ($100)
or less)
1 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
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I 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.)
~ Lendces Name
Landees Address
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
~ building construction, and hereby authorize 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
Y3 liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit
0 f
-� APPLICANT UNDERSTANDS &ND/VfILL COMPLY WITH ALL NON -POINT
Issued t y: Date J
SOURCE GULATT
J � O
Re -roof; --
T Of Roof
Type
SignatureofAppli t/Contractor Dare
HAZARDOUS MA ALS ISCLOSURE
Will the applicant or future building c t 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 shall be inspected prior to any roofing material being installed.
❑ Yes 4°
roofs
If a roo 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?
❑ Yes —ANo
1 have 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 responsibility to notify the occupant of the
-
Date
tcy ircmcnts hick must be mettn' uancc of a Ccr ficate of oc ansy/
S i natu -e of Applicant
—�
All roof coverings to be Class "" or better
Owner or authorized agent Datc
CITY OF CUPERTINO
WATEE HEATER
. CUPEkTINO PERMIT APPLICATION FORM
o 903uo-1 q
APN # _ _ C,A J
Date: /
Building Address:
/ C3
Owner's Name:
Phone #:
C, C
Contractor:
Phone #: C - ? -�j
_ -I r C V '� i ,� y', C:
Fax #: 51C rvG�t - C� 7?
Cupertino Business License #:
Contractor State License #:
3c
7 k1 9�c
Contact:
Phone #:57C -
I<
Fax #: � f C, C -1 7c.
Building Permit Info:
Bldg ❑ Elect
Plumb Mech
Residential"
Commercial ❑
Job Description:
r
Strapped ❑ On Platform ❑ Bonded
❑ New Location ❑ Replacement
Valuation (cost of project):
Project Size: Express Standard ❑
barge ❑ 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
uJPEkT1N0 PERMIT APPLICATION FORM
Quantity
Fee ID
Fee Description
Fee
Group
Permit Type
1PCWHEATR
Commercial Water
HeaterNent
B
PCWHEATR
1BSEISMICOM
Seismic Commercial
B
1
1 PRWHEATR
Residential Water
HeaterNent
B
PRWHEATR
r
l
1BSEISMICRE
Seismic Residential
B
1 PPERMITFEE
Plumbing Permi :
P
/
1 TRAVDOC
Travel &
Documentation
B
1 BUSLIC
Business Licens(;
B
CITY OF
LMkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777 -3228
Fax (408) 777 -3333
Building Department
JOB ADDRESS:
1 -1 a k A io e -
PERMIT #
4�� -r
OWNER'S NAME: \ h -- 1n\ e, n L- % V—, %
PHONE # - 3_
GENERAL CONTRACTOR: ,
FAX #
I am not using any subcontractors:
Si mature Date
Please check applicable subcontractors and convilete 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