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09040149 77, CITY OF CUPERTINOd)�kATI�IY:: BUILDING DIVISION PERMIT PERMIT NO. f �35 S:C ALVE C OUN S I L P PERMIT ISSUE DATE OWNER'S NAME. A CONTROL NO. NE: (4 0 8) 272-2272 BUILDING PERMIT INFO rARCHITECTIENGINNE�ER: �� B� E� PLUMB 0reCLICENSED CONTRACTOR'S DECLARATIONJob DeSCrlptlOn Uby affirm that I am licensed under provisions of Chapter 9(commencing 70(10)ofDivision3oftheBusincssmdProfesst�n�`,andmylicenseis INSTL TI`KLS WTR HTR, NEW 1" GAS LINE FM METER y in full force and eft L 9 Zl/D r License Lam'S Date Contracler ARCHITECPS DECLARA770N 67.-, 1 understand my plans shall be used as public records �Lu LGH Licensed Professional OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the p O following reason.(Section 7031.5,Business and Professions Code:Any city or county r m which requires a permit to construct.alter,improve,demolish,or repair any svecture Valuation y- w prior m its issuance,also requires the applicant for such permit to file a signed statement ; ,Ft.Floor Area z< that he is licensed pursuant to the provisions e!the Contractor's License Law(Chapter 9 q 3900 YF (commencing with Section 71100)of Division 3 of the Business and Professions Code)or e R s 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). 35717032 .01 1,as owner of the property,or my employees with wages as their sole compensation, Required Inspections will do the work,and the structure is not intended or offered for sale(Sec.7044,Business and Professions Code:The Conuacuies License Law does not apply to an owner of properly whe builds or improves thereon,and who does such work hi mseltor through his own emplayea,provided that such improvements are not intended or offered for sale Ir, however,the building or improvement is sold within one year of completion,the owner builder will havethe burden of proving that he did not build or improve for purpose of sale.). I,as otM property.am exclusively convecting with licensed cenvactors m rnrswct Zrthe projen(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 convectors)licensed pursuant to due Contractor's License Law. B&P C for this reason 0 1 am exempt under Sea Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: L]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. 0 1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance or the work for which this permit is issued. My Worker's Compensation insurance carrier and Polity number am: 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 less) I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manne m 'C t to the Workers'Compertsation Laws of California.Date Applicant t NOTICE APPLICANT:If,after making this Ccnlficatc 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� CONSTRUCTION LENDING AGENCY F~•e 4 1 hereby affirm that there is a construction lending agency for the performance of > the work for which this permit is issued(See.3097,Civ.C.) W Q L.entices Name Z Lender's Address U O 1 certify that I have read this application and state that the above information is LL E� correct.i agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorbn representatives of this city to enter upon the O V &hove-mentioned property for inspection purposes �4 nWi (We)agree to save,indemnify and keep harmless Use City of Cupertino against p.4 liabilities,judgments,costs and expenses which may i way accrue against said City Date ( — 2 e'_� U Z in consequence of th g ung of this permit. h-, APPLICANT UND�Jk T DS AND WILL COM WITH A NON-POINT Issued by: RCE REG(;LARe-roof:; S natur of Applicant/Contractor Dare Type of Roof HAZARDOUS MATERIALS DISCLOSURE yP 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(x)? All roofs shall be inspected prior to any roofing material being installed. O /NofuturYesIf a roo�"is installed without first ob Ininspection,I agree to remove Will the applicant or building occupant use equipment or devices which all new materials f inspection. nit hazardous air contaminants ss defined by the Bay Area Air Quality Management District? 0 Yes ° /�•� 1 have read the ha>•ard materials requirements under Chapter 6.95 of the Califon- (� ria Health&Safety Code,Sections 75505,25533 and 25534.1 understand that if tic building does- oes mol curtcn0y ha a tenant,that it is my respo ility to notify oaupanj ter rte nature Of Applicant' Date re uiremcnts which est et prior IO issuance a rtiGcate of pan 77 All roof coverings to be Class"/ "or better Owner or authori�cd a�.Rht Date CITY OF CUPERTINO � oqolqq WATER HEATER COF CUPERTINO PERMIT APPLICATION FORM APN # � O � �t Date: n 129 � O r `^f Buil ing Address: 10435 CJ u e-,P,+ DP, Owner's Name: Phone #: E I I en ee- (? Wo - C16 2 Contractor: Phone #: 468 2-7 Z-z772 ou n t l Plumbi- ng Fax #: Cupertino Business License #: Contractor State License #: 3071514 92(075(0 Contact: P one #: 4C)Cf _ 3-9�(o j C468) I i�e Fax #: Building Permit Info: Bldg ❑ Elect ❑ Plumb Mech Residential Commercial ❑ Job Description: Gab I i YAP-, �Y-o ►yt nq e,�Cg Strapped ❑ On Platform ❑ Bonded ❑ New Location ❑ Replacement Valuation (cost of project): 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: Revised 01/07/09 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 .;UPEKTINO Building Department JOB ADDRESS: /��2 CIG\U Q R-1 PERMIT # On 04-Q n OWNER'S NAME: C � PHONE # `1 - v` GENERAL CONTRACTOR i' I Imbi'YoFAX # Uf I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSI:-4ESS 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 4 ( Owner/C tractor Signattlre Date