05110073 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ;�CO� �CO„ I �DMAxI( ;1 "4 '
BuaDING ADDRESS: AFFORDABLE WATER HEATERS """ NO-05110073
.10777 LINDA VISTA DR
OWNERS NAME: PERMrr ISSUE DATE
JULIA JU 24707 SAN FERN
NE: SANITARY NO. CONTROL NO.
(661) 259-7131
ARCHITECUENGINEER: ,r� BUILDING PER Mff INFO
,rygBvLeDO
ELECT
PLIIMR NECH
1006 LICENSED CONTRACTOR'S DECLARATION Job Description\rJ�
1 I hereby firm thu 1 w 11¢verd under provisions of Chapter 9(onmmdncing
WNS totion 70(10)afDivlalon]afdte Budne WRafndmu Code.W myliecrtma REPLACE WATER HEATER ✓yyy
'+ in full fame ssW er 7
Z LkenmGlu, Lw,dms b
Gen DECLARATION ATION Rt..v.rolw4.A� A�'t.
Ae&Wll use DECLARATION
I ftf tend my pla0.hall he used u public receran �DO�
t LudaJ Pm(csdonal
5 OWNER-BUILDER DECLARATION
1 hereby.(Rnr on I a1.eumm from the Conlon Co :A n c law far the
o O
follow OR reason.(Sedan 71171.7.BYdaOt NO TrfOdau Cods:Any city or county
3$ which acquires a permit to couuueL alter.improw,demnlleh,or rtpab any,uucturt $1000
zC prior in its issuance.aaa requima tis,appliat for each permits,0a wigned aamment
Net as is licensed pursunt w the juavialona of dm Comrxm/s L'ceue Law(Chapter 9 Sq.Ft. Floor Area alua[ion
(commencing with son 7000)W Otvisio.3.f Ne Busin.umW Pmfee...Cade)Or
that M is emmpt therefrom and the basis fu Na alleged emmginm Any violation of
sedan 70315 by am/appiiom for a pum(t mbjeae the.Mlicant w,dyil pointy of _11L j%r;&r"T0 Occupancy Type
not mart thea Rw hondmd dollars($700).
❑1,uWWofIMpropertyormywploycuwithwagcaudeb NleeomPe don,
wtUdoftw rk.snd Ne,au is mtinanaaa«a@twrormle(see.7Da,Butircse Required Inspections
Nd Pmfndom Cade:The connectors;License Law does set apply w,n awns,or q p
property who build,orimprowe demon,and whadoessuchwarkhimselfuthrough his
own emplayems provided mat each Improwmmou am notlmeMW reoffered forme.if.
ho.'ewr.the building or improwment is mid ambinoro year mwmpkfim the rwnmr-
builder,will law the When of preying the bu did on,ddw or Improw for purpose of
❑L u ewncr of the property.am casimewly connecting with BaOed contractors to
muuum the project(Sec.7044,Business and professions Cade:)The Conunames U.
renas Law dm as apply se N.of property-who builds or Winnows theean.and.
who contracts for each pa jew with acannealot(,)licensed personal m th.Commences
License Law.
[3I w exempt undo See .B d PC fm this more
153100
ner Data
WORKER'S COMPENSATION DECLARATION
1 hereby anion under penalty m Pmjmy arc Often fallowing dccledmtc
1 have and will maintain a CerOnumar Content s,self-larva,lor WmWes CamPen- -
ion,u provided for by section 3700 of the Labs,Code.for the peRarmerce of the
ork for which dale permit is ioued.
1 haw Nd will mainWn Woraces Compensation huurance,u required by sedon
of Ne labor Code,far the pcefarmNca ofthe work forwhich this permit is Issuedy Worked,Campadon htmnme crier and policy number am:
rtier:+'41n 1`a- �rnti0 Policy No.:111;)335'— S
CeR77FlC 7_ ii EXEMP ION IROM WORKERS'
COMPENSATION INSURANCE
(Ibis semen and ontbucanpleted if Ne permit it formtehundrW delar,($100)
or wss)
1 sonify Net In thn,pefmamem of the work fm which Nin Permit is issued.I shill nut
employ say person in any moweran u w became subject to dm Worked Compermme,
Laws of Califom(s Dam
Applicant
NOTICE TO APPLICANT:If.after making Na Cenlnnm of Exemption,you should
became subject to tis,Workers Compeuadan pmHswns M N.labor Code,you most
.,O forthwith comply with such provinces or Ni,permit shall bd deemed rooked.
z� CONMUC71ON LENDING AGENCY
[� I hereby aflum NU Nem it a construction hording agmcy far the perfonn.nca of
rl Ne work for which this Permit Is issued(Sm.71447.Civ.C.)
QLenders Nunc
,7 z Lender,Address
V O 1 certify that I Mw mad Ni,application and,em mm the abuw information in
F cared 1 agree w empty with dl City and county omiuMet and tate law,minting W
O V building conwncdon.and Mmby wthorim repommodwe of Na city to enter upon the
lig anew-mendomed property far inspection purposes
(We),gree maw,indemnify ad keep harmless tis,City of Cupertino 19-109
liabilities.judgmenu,cow had expenses which may in my way seem Against cid City
V z
mc
n eonsequenee a 'ng of Nu Mill.
APPLICA ANDS AN WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU
�os Re-roofs
SI art alAppliauConuscwr
Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building accupmtuom or handle havudeu material
as deBOd by the Cupertino Municipal Code.Chapter 9.13.and dw Health end Safety
Section add.Sean 2553:(.)7 / All roofs shall be inspected prior to any roofing material being installed.
❑Y0
Will the applicant or future building occupant um equipment or devk s which If a roof is installed without first obtaining an inspection,I agree to remove
..It Mwdou airwnuminamu n defined by the Bay Arta Air Quality Management all new materials for inspection.
Disuict7 —/
❑Yu Lyne
I haw mad the hanolues materials nequhcmew under Chapter 6.95 afthe Califa-
muHcalNlSarct Codd,Sections 37705.25573 mW 25531.1 undemmed Nm if me Wilding
does not careen am a teat,Net it a my mnpoui ty to sadlytily the=Van'of tis,
mquimm be cols, amm
prorissa cedncateofOccupancy. Signature of Applicant Date
a
Dam All roof coverings to be Class"B"or better
own raraeNadma.en,
Community Development
x 10300 Torre Avenue
( p, Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
9UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
077? 6 N Dp r,6 a-✓
OWNER'S NAE: et �-'cPHO
MNE #661-255- 7/3/
GENERAL CONTRACTOR: Fr-ervn e 1� FAX # &C/- 2 s -s sry
I am not using any subcontractors: ;,—
it
Signature Date
Please check applicable subcontractors and complete the followin 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 /
Date
wner/Contractor Signature
O
CITY OF CUPERTINO
WATER HEATER 72
CUPEkTINO PERMIT APPLICATION FORM
APN# �� D o/ Date:
Building Address:
0777 (,inrDn VJsd
Owner's Name: Phone#:
_),.t\I k -3ti
Contractor: Phone: License7-#:
1frOrOnfj74 LvAlerHe^d,i ��\ o (061 - 2S"— C,5 62 3
Contact: Phone: Cupertino Business License#:
of C�Sf Sz
Building Permit Info:
Bldg ❑ Elect MZ ' Plumb ff� Mech I!
Job Description:
1r5{�II Wna�. ��„t•r
Residential ❑ Commercial ❑
Cost of Project:JD 6o
Strapped 11 ! On Platform El Bonded El
• New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
3 r 9 ��--
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