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09060096 CITY OF CUPERTINO BUILDING DIVISION PERMIT . , � � ' PERMIT NO. BUILDING ADDRESS: 10801 JOHNSON AVE CHARLES PERMIT ISSUE DATE OWNER'S NAME: CALDWEL L S A CONTROL NO. `N BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH 0 0 o a a p p LICENSED CONTRACTOR'S DECLARATION Job Description U I hereby affirm that I am licensed under provisions of Chapter 9(commencing cu with Section 7000)of Division 3 of the Business and Professions Code,and my license is � y in full force andeffmt. REPLCE 1 WATER LINE & .WTR HEATER, REPLC 5 FIXTURS D Z License Class Lic.M Date Comracwr & REPLC 60 ' (APPX) OF SEWR LINE .� ARCHITECTS DECLARATION � I understand my plans shall be used as public records 5wd too H Licensed Professional y 3 OWNER-BUILDER DECLARATION I hereby M. that 1 am exempt from the Contractor's License Law for the 'COO following reason.(Section 7031.5,Business and Professions Code:Any city or county .4 m r which requires a permit to construct,alter,improve,demolish,or repair any structure y Z} prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation _ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area x F- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 4 y $ that he is exempt therefrom and the basis for the alleged exemption.Any violation of 500 Section 7031.5 by any applicant for a permit subjects the applicant 10 a civil penalty of APN Number Occupancy Type not more than five hundred dollars(5500). 3 7 5 310E 2 . 0 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 Required Inspections and Professions Code:The Contractors 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.U. 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 r, sale.). ❑1,as owner of the property,am exclusively contracting with B«naed contractors to jJ, r s construct the project(Sec.7044,Business and Professions Code:)The Contractors L)• cense Caw 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 ContractorsLicense Law. ❑1 amexempt u r Sec B&P C for this reason Ownertj&� Dare WORKERS COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: have and will maintain a Certificate of Consent to self-insure foe Workers Compels- -son,as provided for by Section 3700 of the Labor Code.for the performance of the work for which this permit is issued. ❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Workers Compensation Insurance carrier and Policy number are: 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.) 1 certify that in the performance of the work for which this permit is issued.1 shall not employ any person in any man rtGr so as tq bccomc spb* Ito the Workers'Competuadon Laws of caliril Date ! / rJ 4 Applicant •Ify NOTICE TDkOPLMANT.If,aTicr making this Certificate of Exemption,you should become subject to the Workers Compensation provisions of the Labor Code,you must Oforthwith comply with such provisions or this permit shall be deemed revoked. Z R CONSTRUCTION LENDING AGENCY i1-i I hereby affirm that there is a construction lending agency for the performance of p(,✓ the work for which this permit is issued(Sec.3097,Civ.C.) W ALenders Name ]z Landers Address U C) I certify that I have read this application and stave that the above information is 44 correct I agree to comply with all city and county ordinances and state laws relating to 0 V building construction,and hereby authorim representatives of this city to enter upon the U above-mentioned property for inspection purposes (We)agree to save,indemnify and keep harmless the City of Cupertino against hF"t Co] 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 UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b): S uycuLION Re-roofs !ftg'Rature of A•ppli acam/contractor 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(x)? t� All roofs shall be inspected prior to any roofing material being installed. ❑Yes y]No /�j 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 hazardous=cd by the Bay Area Air Quality Management all new n laterials for inspection. ,uict? ❑Yes1 havererequirements 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 M the requi me whit ass I nor to i trance of a Certificate of Occupancy. Signature of Applicant Date All roof coverings to be Class'A�'or better wner or authorized agent Date (qq C)(,0 CITY OF CUPERTINO WATEI1 HEATER CUPEi�TINO PERMIT APPI:JICATION FORM APN # � Date: -7� �5 I (P9 , Building Address: TV h naso,, 04k--e Owner's Name: Phone #: Contractor: (l,c, Phone #: Fax #: Cupertino Business License M Contractor State License #: Contact: q0S �,�� 3,W z Phone #: Fax M Building Permit Info: Bldg ❑ Elect ❑ Plumb Mech ❑ Residential X Commercial ❑ Job Description: ��' Strapped On Platform) ❑ Bonded New Location ❑ Replacement Valuation (cost of project): ySOb 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 CITY OF CUPERTINO ` WATER HEATER CITYCUPEf�T1NO PERMIT APPLICATION FORM Quantity Fee ID Fee Descripti,)n Fee Permit Type Group 1 PCWHEATR Commercial Water B PCWHEATR HeaterNent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission F'ee 1BSEISMICOM Seismic Commercial B 1 PRWHEATR Residential Water B PRWHEATR HeaterNent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission I'ee 1BSEISMICRE Seismic Residential B 1PPERMITFEE Plumbing Pennit P 1 TRAVDOC Travel & B Documentation 1BUSLIC Business License B OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate family parent,spouse or child) will perform: A. All the work authorized by this permit B. A portion of the we-rk C. None of the work If B or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hirec[to do: A. All of the work B. A portion of the work (complete section below) Contractor Address/City. Phone # State License # Type of work to 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer(see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. PersorVFirm Address/City . Phone Number Type of work to be performed ............................................................................,........................ I declare under penalty of perjury that the a rove is true and correct. I have read and understand the Owner-Builder Information (reverse side). Property Owner's Signature: i Date: p rtvogo(p®0 Job Address: `�� S�'J _ Permit# Any changes to the.information provided on this form shall be submitted to the City of Cupertino Build Department. Community Development 10300 Torre Avenue ' Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 'r,UPEkTINO Building Department JOB ADDRESS: PERMIT# Ga o OWNER'S NAME: > PHONE # . — '-T<Pe GENERAL CONTRACTOR: FAX # I am not using any subcontractors: 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 01��" (a-'��o —©r Owner/Contractor Signature Date