09040157 777777r77 77 77
CT__1
CUPERTINO
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS:
7546 NORMANDY WAY AFFORDFBLE WATER HEATER & 09040157
PERMIT ISSUE DATE
OWNER'S NAME:
ANN VAN SANttM O. 0 9 9 CONTROL NO.
ONE:
BUILDING PERMIT INFO
ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH
RPLC WTR HTR, SAME LOC Q D D O
Q p LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
,5 with Section 7000)of Division 3 of the Business and Professions Code,and my license is
y in full force and effecL� (4
Z License Class I'c N
-G Date 1' G Contractor
gt
r9 ARCHITECTS DECLAR N
g a-,U I understand my plans shall be used as public records
�y
U.y Licensed Professional
O< 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
e m P which requires a permit to construct alter,improve,demolish,or repair any structure
y"H prior to its issuance,also requires the applicant for such permit to file a signed statement .Ft.Floor Area Valuation
- < that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 �l
XF t] (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
a that he is exempt therefrom and the basis for the alleged exemption Any violation of APN Number Occupancy Type
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars(5500).
❑I,as owner of the property,or my employees with wages as their sale compensation,
will do the work and the structure is not intended or offered for sale(Sec.70".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.).
❑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 u-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a conaractor(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 Worker's Compen-
...tion,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 Polity number are:
Cartier. -+ t � _Policy No.: Zai t t aLk CS All I
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 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 Cade,you must
,J Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z 2 CONSTRUCTION LENDING AGENCY
[~-o I 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 Lender's Name
Lender's Address
1 certify that 1 have read this application and state that the above information is
LUL cortect.I agree to comply with all city and county ordinances and state laws relating to
U building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes
>4 W (We)agree to save,indemnify and keep harmless the City of Cupertino against
co) liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit LI&...Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 7
SOURCE REGULATIONS ��. -- V-2. Re-roofs -
Signature of Appli ontractor Dare 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.
❑Yes If a roof s installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
it hazardous air contaminants as dcfmcd by the Bay Area Air Quality Management all new materials for inspection.
strict? y
❑Yes A
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
requirements which he met prior to issuance of a Certificate of Occupanty. Signature:of Applicant Date
i. -�01 C'c All roof coverings to be Class'n"or better
Owner or au ed agent Date
CITY OF CUPERTINO oC1 O`"I 0 ( ,5 �1
WATER HEATER
CUPEI�TINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
Owner's Name: Phone #:
Contractor: Phone #:
Fax #:
Cupertino Business License #: Contractor State License #:
1 7 s (_�
Contact: Phone #:
Fax #:
Building Permit Info:
Bld ❑ Elect a Plumb El Mech 9--
Residential 0 Commercial ❑
Job Description:
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: <!S=
Revised 01/07/09
CITY OF CIUPERTINO
f,S21, WATER BEATER
CITY Of
CUPETRINO PERMIT APPUZATION FORM.
Quantity Fee ID Fee Descriptic n Fee Permit Type
Grou
1PCWHEATR Commercial Neater B PCWHEATR
HeaterNent
1BCBSC Cal Bldg Stanc.ards B ALL PERMIT TYPES
Commission F-.e
1BSEISMICOM Seismic Commercial B
1PRWHEATR Residential Waiter B PRN HEATR
HeaterNent
� 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
1 Commission Fee
1BSEISMICRE Seismic Residential B
1PPERMITFEE Plumbing Pennit P
1 TRAVDOC Travel & B
Documentation
1 BUSLIC Business Lice.lse B
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
`CITY OF Fax(408)777-3333
7UPERTINO
Buildin De artment
JOB ADDRESS: PERMIT #
OWNER'S NAME: 4�\,h PHONE # `(a3- 4-5-I- C'`t "1 3
GENERAL CONTRACTOR: t4i-jt 4 :� IFAX #
I am not using any subcontractors: t -I. �� L
Signature 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
O" er/Contractor Signature Date