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09030026CITY OF CUYhxi uw BUILDING DIVISION PERMIT BUILDING ADDRESS: 7515 KIRWTN LST - OWNER'S NAME: uadz 00 wM rA rnr Z 2 -Lu 49< �C6 Eo CA ynyy y<00 o� "za EFG i X �- 1) 25'l-7 ARCHITBCr/ENGINEER: LOl=1J 1v -.,.------_--_- I hereby affirm that I am licensed under provisions of Chapter 9 (commencing PERMIT NO. PERMIT ISSUE DATE S p CONTROL NO. BUILDING PERMIT INFO BLDG EO PLUMB Job Description with Section 7000) of Division 3 of the Business and professions Code. and my Itceoae hs101, REPLACE 40 GAL WATER HEATER n fuliK�ARCHrrB_717S Lc x Z 3 f.40 --cenDateContractoNl DECLA ATION 1 understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county which mquims a permit to concoct, alter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's Gcensc Caw (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therea�cant for a and the perm subjects the app► cis for the alleged pantto a civil rolation of penalty of Section 7031.5 by arty applicant Tx Sq. Ft. not more than five hundred dollars ($.500). 35919032.00 0 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 sale (Sec. 7044, Business and Professions Code: The Contractor's License Law dors 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 win have the burden of proving that he did not build or improve for purpose of sale.). Q I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Caatractces U - cense Law does not apply to an owner of property who builds or improves themon, and who contracts for such projects with a contractor(s) licensed pursuant to the contractor's License Law. B & P C for this mason I am exempt under See Owner Dare WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: ❑ 1 hsae 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 Worke ompen on Insurance carrier and Policy number are: d Cartier. 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 loss) 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. Dare 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 ,J ,'Z forthwith comply with such provisions or this permit shall be deemed revoked. Z O CONSTRUCTION LENDING AGENCY I hereby affirm that there is a concoction lending agency for the performance of Q( > the work for which this permit is issued (Sec. 3097, Civ. C.) W A Lendces Name 0 z Lender's Address V 0 1 certify that 1 have read this application and stare that tuc above information is LL cored 1 agree to comply with all city and county ordinances and state laws relating to 0 V building conswction, and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes f Cupertino against LL (We) agree to save, indemnify and keep harmless the City ° t� t;.-) liabilities, judgments, costs and expenses which may in any way accrue against said City V Zin consequence of the granting of this permit. �+ APPLICANT U STANDS AND WILL COMPLY WITH LL NON -POINT SOURCE LAnONS. Signature of Meant,Contractor Date HAZARDOUS MATERIALS DISCLOSURE 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)? ❑ Yes ° Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants u def cd by the Bay Area Air Quality Management District? Dyes ° 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 cummntly have nant, that i% my responsibility to notify the occupant of the requirements wh' u� t � r to issuance of a Certificate f �ccupp� G/6 Owner or authorized agent Date Issued t Re -roof Type of Roof Area Required Inspections Occupancy All roo''s shall be inspected prior to any roofing material being installed. If a roo` is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant All roof coverings to be Class'{`' or better Date CITY OF XPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOBS DRESS: Kv'W'jrJ PERMIT # 0 3 OWNER'S NAME: A L6 D PHONE # Lloh GENERAL CONTRACTOR: 4f 4-1 At F # I am not using any subcontractors: ;signature Date Please check applicable subcontractors and coinvlete the followiniz 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 CITY OF CUPEkTINO CITY OF CUPERTINO WATER HEATER PERMIT APPLICATION FORM 09D3�X 2C_,o APN #S�� 03�� Date: /G / 0 3 Building Address: -7 �� r w', rJ�ti r -J Owner's Name: Phone #: y ods S(,1� .-/ z 7 r �M,f-i,E— Contractor: Phone #: & (A -- -713,,l Fax #:(p 6/- 2 5-y-9ST6 Cupertino Business License #: Contractor State License #: & -Z Contact: Phone #: S 0'�T L -� L Aa W /J Fax #: JfGi- 2_rf-9s30�- Building Permit Info: ff Elect Pluml,Er Mech ®� -Bldg Residential Commercial ❑ Job Description: Strapped On Platfo Bonded ❑ New Location ❑ Replacement Valuation (cost of project): 1 ko ---- Project Size: Express E--Standa ,rao 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. 6�_) Green Building Points achieved: Revised 01/07/09 CITY Of CUPEI,TINO Quantity Fee ID CITY OF CU7PERTINO WATER BEATER PERMIT APPLICATION FORM Fee Description 1 PCWHEATR Commercial VA'ater 13 rL w ri�ti 1 n HeaterNent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICOM Seismic Commercial B IIPRWHEATR . l 1BCBSC 1 BSEISMICRE Residential Water HeaterNent Cal Bldg Standards Commission l; ee Seismic Resic.ential 1PPERMITFEE Plumbing Permit 1 TRAVDOC 1 BUSLIC Travel & Documentation Business Liconse