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09030027 CITY OF CUPERTINO BUILDING DIVISION PERMIT BUILDING ADDRESS: PERMIT NO. 20073 WHEATON DR AFFORDABLE WATER OWNER'S NAME: PERMIT ISSUE DATE PAN N RNT=T=R9A4D AVE . .,ONE: SXMtAAU2 CONTROL NO. (661) 259-7131 ARCHITECUENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH !00 LICENSED CONTRACTOR'S DECLARATION Job Description U3 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing z with Section 7000)of Division 3 of the Business and Professions Code,and my license is <o in full force andeif6 (oZ7 36 Y REPLACE 4 0GAL WATER HEATER Z License 3 Lic.ff n F p Dare Contractor AR HTTECTSDECLARATION < I understand my plans shall be used as public records D U Oy Licensed Professional .1 OWNER-BUILDER DECLARATION g� 1 hereby affirm that 1 am exempt from the Contractors License Law for the Ofollowing reason.(Section 7031.5,Business and Professions Code:Any city or county K which requires a permit to construct,alter,improve,demolish,or repair any structure Zprior 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 License Law(Chapter 9 Sq.Ft.Floor Area Valuation F_ = (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $1600 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 APN Number Occupancy Type not more than five hundred dollars(SSM). 31623055 . 00 ❑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 Required Inspections and Professions Code:The Contractor's License Law docs not apply to an owner of fl 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.). ❑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 Li- 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 See 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 Worke^es�Comppens�at,�oonn Insurance carrier and Policy number Cartier :""' r ' Polity No.?O7� 7 6 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 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 Oforthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY [~—t 4 I hereby air.that there is a construction lending agency for the performance of fx.7 the work for which this permit is issued(Sec.3097,Civ.C.) WG1.Q Lender's Name Z L.endees Address U 0 1 certify that 1 have read this application and state that the above information is L1;.t"' correct.l agree to comply with all city and county ordinances and state laws relating to 0 V building construction,and hereby authorize representatives of this city to enter upon the a above-mentioned property for inspection purposes (We)agree to save,indemnify and keep harmless the City of Cupertino against V) liabilities,judgments,toss and expenses which may in any way steric against said City /, I U Z in consequence of the granting of this permit. Date CI v �+ APPLICANT UNDERSTAND AND WI L COMPLY WITH ALL NON-POINT Issued by SOURCE EGULATIO G o Re-roofs Sign pplicant/Contractor D81C 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 ;hall be inspected prior to any roofing material being installed. ❑Yes . If a roof i;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 �t4o 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Cade,Sections 25505.25533 and 25534.1 understand that if the building does not currently have a an that it is my responsibility to notify the pant of the requiremcnts wh' issuance of a Ccrtificatc Q QC aqer/� Signature of Applicant Date /G. ( O All roof coverings to be Class" "or better Owner or authorized agent Date Community Development z a=„ 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 ..UPERTINO Building Department JOB ADDRESS: PERMIT# ZU67S WV,,e,. �v r T> OWNERS NAME: e( ��,�— PHONE #(obl z s S 2/y GENERAL CONTRACTOR: FAX # I am not using any subcontractors: v t Signature Date Please check applicable subcontractors and coni 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 Owner/Contractor Signature Date CITY OF (�r".UPERTINO r WATER HEATER CUPEIkTINO PERMIT APPLICATION FORM APN �� Date• 1Lo 21, 057, 3 Building Address: Z.a6'7 3 W 'c'K � V� V""- Owner's /Owner's Name: Phone #: yp&_ `-- Flea Contractor: Phone #: l�� orD�f31 e WcJre � Fax #: &��- 2 5S•- Cupertino Business License #: Contractor State License #: (02 73 � �- Contact: Phone #: -,?5T—:71 Fax #: Building Permit Info: Bld Elec Plumb Mech ©� r" Residential Commercial ❑ Job Description: Strapped On Platform Bonded New Location ❑ Replacement-- Valuation (cost of project): /boo �---- l Project Size: Express ❑ Standard Large ❑ Major ❑ Green Building: Please complete relevant po rtion 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 01/07/09 CITY OF CUPERTINO WATER HEATER CUPCITYEf�T1NO PERMIT APPLICIATION FORM Quantity Fee ID Fee Description Fee Permit Type Grou 1PCWHEATR Commercial )Nater B PCWHEATR HeaterNent 1BCBSC Cal Bldg Stanc.ards B ALL PERMIT TYPES Commission F,-e 1BSEISMICOM Seismic Commercial B 1 PRWHEATR Residential Water B PRWHEATR HeaterNent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES r Commission Fee / 1BSEISMICRE Seismic Residential B f 1PPERMITFEE Plumbing Pennit P 1TRAVDOC Travel & B Documentation 1BUSLIC Business License B