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09030025 CITY OF CUPERTINO � , BUILDING DIVISION PERMIT BUILDING ADDRESS: PERMIT NO. 20888 GREENLEAF DR AFFORD ,BLE WATER HFATRRq r- n9030025 PERMrr I5SsUE DATE OWNER'S NAME: LAFEWRES AAtt2 8 0 9 CONTROL NO. r10 661) 2 ,9-7131 BUILDING PERMIT INFO ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH app LICENSED CONTRACTOR'S DECLARATION Job Description m6 I hereby affirm that I am licensed under provisions of Chapter 9(commencing Z m with Section 7000)of Division 3 of the Business and Professions Code and my license is REPLACE GAS WATER HEATER e y in full force ana�L=RRRCH=1F1f, f6 2'7 3` i do Z License Cl Co g F•o DateContractor W R rS DECLARATION I understand my plans shall be used as public records D,u 4 C ti Licensed Professional OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the in O following reason.(Section 7031.5,Business and Professions Code:Any city or county K which requires a permit to construct,alter,improve,demolish,or rcpalr any swcture Z} prior m its issuance,also requires the applicant for such permit to frlc a signed statement Ft.Floor Area Valuation _ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $1796 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 APN Number Occupancy Type not more than five hundred dollars($500). 32630168 . 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 sale.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044.Business and Professions Code:)The Contractor's U- 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. ❑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: ❑1 have and will maintain a Certificate of Consent to self-insure 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. ❑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 number am: Cartier:—7G�f� Polity No.:ZdO(0 784 9 7 03 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Phis section need not be completed if the permit is for one hundred dollars($100) or Icss.) 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 Z forthwith comply with such provisions or this permit shall be deemed revoked. Z 0 CONSTRUCTION LENDING AGENCY [�CA I hereby affirm that there is a construction lending agency for the performance of (3;5 the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lendces Name ] Z Lendees Address U C) I certify that 1 have read this application and state that the above information is LL► correct.l agree to comply with all city and county ordinances and state laws relating to 0CF.) building construction,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against 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 UNDER ST NDS D WILL COMPLY WITH ALL NON-POINT Issued by: SOUR964GUL L_JZ616fRe-roof; SignaturcofApplicant/Co for Date T of Roof HAZARDOUS MATERIALS DISCLOSURE Type 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. [3 Yes O Will the applicant or future buil Ing accupant use equipment or devices which If a room is installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as fined by the Bay Arca Air Quality Management all new materials for inspection. District? C3 Yes No 1 haveread 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 no y the occupant of the requirements which must mel prior to issuance of,efertir)cate)�?;Pancy. Signatu)-e of Applicant Date U 6 / V All roof coverings to be Class'"or better Owner or au ariz Date Community Development ~� 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 �C1TY OF Fax(408)777-3333 XPEkTINO Buildi:n De artment JOB ADDRESS: PERMIT # OWNER'S NAME: )(VO—jr— C vq ��V L PHONE # y bar-9 7.3—`>S/> GENERAL CONTRACTOR: 14fWFAX # using subcontractors: �' 6 I am not g any ;nature Date Please check applicable subcontractors and complete 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 CUPEI�TINO PERMIT APPLICATION FORM () 0 25r APN # � � Date� • Building Address: ,,2 6 �� G re Ce-:L Owner's Name: Phone #: yV rl� t�f � Vr � LIDS- y73- V2 © l Contractor: Phone #: 02.E 5 713 Fax #: Cupertino Business License #: Contractor State License #: Cry'z73 (-,8' Contact: Phone #: &41- QTS^ 713 J SC (, 4-4 L J1 Fax #. G Z Building Permit Info: Bld Elect [S� Plumb Mech [�— Residential Commercial ❑ Job Description: C � W Strapped On Platform Bondecl,,a New Location ❑ Replacement Valuation (cost of project): t ,7� C 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: &2 Revised 01/07/09 CITY OF C UPERTINO J. WATER HEATER CUPEi�TINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Permit Type Group_ 1 PCWHEATR Commercial `Nater B PCWHEATR HeaterNent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission J;ee 1BSEISMICOM Seismic Commercial B 1PRWHEATR Residential Water B PRVvHEATR HeaterNent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee I 1BSEISMICRE Seismic Residential B 1 PPERMITFEE Plumbing Permit P 1 TRAVDOC Travel & B Documentation 1 BUSLIC Business Liconse B