05010132CITY OF CUPER7'[NO
-"�Y4. s' �°*dr v-',iis#"<11`€:i
BUILDING DIVISION PERMIT
IX�NTRACTOR INFORMATION ?.
Du1LDI NO ADDRESS:
WATER HEATERS ONLY
PERMIT "905010132 '
OWNER'S NAME:
PERMIT ISSUE DATE
KENNETH FRI D
01/24/2005
ONE:
SANITARY NO. CONTROL NO. -
800)835-5946
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I
1 afar that
.form that 1 am under provisions of Chapter 9 (commonscis
9(mmmcenuis
a , o ismaiof
Job De I 0
�Q . As Wm
Rd
with 5 on3o(thbsed
Section Code,
ion 7 of the
NA
Lice °^d°ff 3 -7 N 7
'aryl
taj"—J'
REPLACE WATER HEATER
Licg
Dem Cuntramor '
ARCHITECTS DECLARA O
I undc.land my k used ss rtcards
n
plans.hall public
2005
FEBtCI] a a. o
Licensed Professional
OWNER-BUILDER DECLARATION
r,
1 herchy afros that 14M exempt from the Contractors License Law rat the
fallowing recon. 7(131.5, Business and Code: Any city m county
unl� DIN"S"
��
which requires .psi, i n, derma
la Mnarmm, °Iles improve, demolish, or repair any tatucmm
0 0 0
n e,imil
permit m icor a Sega( statement
Prior m its issuance, also requires Ile applicant the Contractor',
the theeBusinersnd orm
he encing
itPursuantection
Sq. Ft, Floor Area
Valuation
with7 of Divions sion 3 G(ion or
(commr the Proflsw(Chapter CaoIc)9
basis f
Nat k V exempt them(rom sod the btu for doe allbdcd eamption. Any violation of
that M is exam donations s and the the alleged axe pt on. Any vi
Q
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to o civil penalty of
not more Nen fin hundred della. ($500).
❑ Luowner of the pmperty,mmy employees with wegq utheir role compenuuon,
Required Inspections
will do the work, and Ne structure Is not Intended or olfemd formic (Sec. 70". Business
nod Professions Cade: The Convector's Lt.. Law does not apply to an owner of
property who builds orimproves thereon, and who does such work himself or through his
own employcw, provided Nalsuch lmprovemenu ve nm intended oroResed for ala 11
.
however, the building or improvement 15501d Withinmet year of eamPleuoe. the owmr-
Wilder will ban Ne burden of pmving Nat W did not Wild or impr"w fur purpose of
.
sole(.
❑ I. as owner of the properly. em exclusively cremating with licensed contractors to
commuter the project (See. 7004, Business and Professions Cotler) The Contractor' U:
come Law does not apply to an owner of property who Wilds or improves thereon. and,
who contracts for such pmjecu with a contraclor(s) licensed pursuant m the Contractor's
License Law.
❑ I am eampl under Sec. . B & P C fm thp moon
Owner Due
WORKER'S COMPENSATION DECLARATION
1 hereby &Man under penally of perjury one of the fallowing declarations:
I ban and Will maintain a CeruOeata nfC..m m .](.Iran. for Wmker'aCampcn-
cation, u provided for by Sestion 37W of the Labor Code, for Ne performance of ftwad
for which this permit is iuucd.
1 have and will maintain Wurkrrs Compensation Insurance, as required by Section
3]00 of the Labor Code. far Ne performance of the work for which this permit is issued
,
My Worker's Compensation Insurance artier and Policy number art:
Gmar: • S • 14 — 0.-• Policy N..;515_0' a 4 1 1
CERTIFICATE OF FXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This.0hm need mA W.moolmed link .it is forare hundred delta. (SIM)
ver lass.)
,
I cattily that In the performance of the work for which his permit is issued, I shell nor
employ any Noon in any manner an as in braome subjesuo the Wmkri Comperostion
Laws of C.lif..u. Dam
Applicant
NOTICE TO APPLICANT: Ir. after making this Certificate or Exemption, you should
Wcome subject m the Workers Compensation provisions of the labor Code, you most
forthwith comply with such provisions or this Permit Mall k deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a cDmtmcdnn lending agency far thr performane,of
the wort for which this permit is issued (See. 3097, Civ. C.)
Lcnder'a Noma
Isnder's Addreu
I cenify that I hens mad this application and tum that the above information is
bonding I .gra to comply with all dry and aunty ordinances and cute laws reusing to
building construction, mprrsemeuves of this city 1°enter upon dm
aWn- "Iyhcrebyatharim
W properly find Purposes
/yam
an
(We) agree to cave, indemnify and keep yinharmless Ile y cityor
(We) indemnity
expcucamit. may In anyway accmc against aid City
against id City
"'OJ
incoIlabiliusquenc oftheensuing
of the granting or this permit.
A
APPLICANT
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date
SOURCEREGU
� -�� teata o S
Re-roofs
-
Signawrc of AppliesnUC trseror Dase
HA ARDOUS MATERIALS DISCLOSURE
Type of Roof ,
Will the applicant or future building occupant stem or handle hr.rdous materiel
ucalmed by the Cupertino Municipal Code, Chapter 9.12. end the Health and Safety
add. Section 25532(a)7
roofs shall be inspected prior to any roofing material being installed.
❑Yes 1,10.1iAll
If a roof is Installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding occupant use equipment or dcviaa Which
in harudaus sit contamin u u d fired by the Bay Arta Air Quality Management
all new materials for inspection.
n7
❑Ya u
I hen read the h..door materials requirement under Chapter 6,95 of the Celifor.
nice Realde & Safely Code. Sections 23305.25533 and 25530.1 umkrsuM div if the Wilding
does rre
not smartly hew a mnana that II is my reepomibillly m notify Ile occupat of the
reyuim u'W esu metpdormanctol'a Ccmflcgw DfColiftioncy
Signature ofApplicant Date
All roof coverings to be Class "B" or better
Owner
or authorized age Dam
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Cl OF Fax (408) 777-3333
IOUPERTINO
Building De artment
JOB ADDRESS:1 0(0 g
� �
PERMIT v 5 o 1 U 1 3 2
OWNER'S NAME:
Q ,,
PHONE # 7
GENERAL CONTRACTOR
-Q-
FAX #
I am not using any subcontractors: ;J W'.z-a - \z f, %%tea D / OS
ignature Date
Please check applicable subcontractors and complete the following information:
i",-4 ��q7L (-�f -
Owner/ Contractor Signature Date
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
i",-4 ��q7L (-�f -
Owner/ Contractor Signature Date
U
CUPEkTINO
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
oSolo025-
APN #
J
C ! S
Building Address: ZDV 8 %i
PPERMFFFEE
Owner's Name:
�
Phone #:A
'/J'-/ (� - 2-7 / 7
Contractor:1Da&.c) J /� 4 hone�00 $ 5 - S 9�i �
IV
License #: ,2) -7y S 7 3
Contact: hone:
Cupertino Business License #:
Business License
r �gL91�
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Mech ❑
Job Description: a,c�z- 5uw
Residenti Commercial ❑
Cost of Project:
G� • a -b
Strapped On Platform 13 Bonded El
New Location ❑ Replacement
Qty. if
Annlicable Fee m
Fee Deccrintinn
Fee Groun
BPWHEATER
Water Heater / Vent
BUILDING
PPERMFFFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING