04050110 (2) ------------
' CITY OF CUPERTINO
s BUILDING DIVISION PERMIT �CONRATORNFUItM�.TIpN'
s s
BUILDING ADDRESS: HOT WATER INC PERMIT NO 04050110
1455 POPPY WY
OWNER'S NAME: PERMIT ISSUE DATE
NANDITA PAI 2531 GRACE
sNE: SANITARY NO. CONTROL NO.
(650) 298-8494
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a a a a
uOp LICENSED CONTRACT'OR'S DECLARATION ��
rd 1 hereby affirm Neu 1 em f he Rea under provisions of Chapter 9(rommense is Job Desc�lt AL E
with Sanson e,air,.
of (hot I am lieu sed in der pr Professions hapten 9(com my cease is
M
mmBNmeamdeffect�7{ Z REPLACE WATER HEATER
a!~Z DlAmnu A�CHHITECI'S DECLARATION /.
Y I understand my plans shall he used u public records DEC 2004
5yU
G Licensed Professional
OWNER-BUILDER DECLARATION B U��®�N
+� 1 hereby.(Sinn on 1 1. exempt from dtc Contractors Code:Any c Law for IM
E O o which ng recon.permit
t 71131.3,Business and we,de ions h.cuAny city or county
I$- which its issuance,
a also re eonswm,sm,pplic improve,demolish,nr repair any tatucture ement
_Zy that hor e inensedlsumto theres Nevisiosofant for uchractor Limme,o file a Laed w(sWcmcnt
a that me cngwitpSewanu0thcprovisionsoftheheBusines'sLiccnselsw(Chaplcr9 Sq.Ft.Floor Area
Valuation
B that he(commencing Section70K)and
the
hasixt pr the
theeged Business and Professions Code)of
.. Net he ta exempt therefrom end Ne buil for Ne alleged exemption.Any violation or
Section 7031.5 by any Applicant for a permit ubjccts the applicant to a civil penalty of 3 @&MmaerO 0 Occupancy Type
not mom than Rw hundred dollars($500).
❑I,o owner of Ne pmpeny,or my employees with wage u Iheirsole compenudon,
willdothome,k and themwaum Is not intended or offered Ronnie(Sec.7044.Business
and Profusions Code:The Common's Limnm Law docs not apply In an owner of Required Inspections
property who builds or improves these.Andwho doessuch work himselfor through his
own employes,provided that such improvementa art not intended uroffered for sale.if.
however,the building or improvement is Gold within one year of completion.the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sole.).
❑1.as owner of the property,am exclusively contracting with licensed eonvacmrs to
convect the project(Sec.7004,Business and Profusions Code:)The Conuacur's Li
cense law docs not apply an an owner of property who builds or improves demon,and,
who contracts for such pmjecu with a commuctor(s)licensed pursuant o the Contractors
License Law.
[3I an,tempt under Sao. .B k P C for this moon
Owner Dam
WORKER'S COMPENSATION DECLARATION
40 1 thereby affirm under penally of perjury one of the following declarations:
I have and will maintain a CeniRau of cement o self-iuuro for Workers Comfort.
miles,as provided for by Section 37x0 of the labor Code,for the perforromm of the
work for which this permit is issued.
ave and will maintain Worker's Compensation Insurance,as required by Section
3 of Ne labor Code.for the performance of fee work for which this Permit is leaned.
My W0rkeri Cnmpeoation lns�u�n'nc�e ca�nim enup olicy num�bs�ar(e/: �7�
Carrico��Policy FROM
WORKERS'C,I��
CERTIFICATE OF COMPENSATION
NFROM WORKERS'
COMPENSATIONINSURANCE
(ibis section mod not la:completed if the pmmit is fmonehundred dollars(Slip)
or Mss)
1 certify that in the performmce of the work for which this permit is ioued.I Nall not
employ any person in any manner an as to become subject to the Workers Compensation
Laws or California.Dec
Applicant
NOTICE TO APPLICANT:If.after making this carldicate of Exemption,you should
become subject in the Worker's Compensation provisions or the Labor Code,you must
.J O fonhwith comply with such provisions or this permit shall be decreed revoked.
„zi 14CONSTRUCTION LENDING AGENCY
1lamhy affrm Nm there ie a consoce inn lendingagency for the perfmchat.of
Qi > the work for which this permit is inamed(See.3097,Civ,C.)
QLender's Name
Q z Lcnders Add.
V Q I certify that 1 have read this application and scale that the show information is
{I. f" correct.I agree to comply with all city and county ordinances and state laws relating to
Q V building convection,and hereby authmim miuman owes of this city to enter upon Nc
fit above-mentioned property far inspection purposes.
gy (We)agree to save.indemnify and keep harmless the City or Cupertino against
e,y A liabilities.judgment,costs and expenses which may in any way accrue against mid City
V Z in consequence of the Stating of this permit.
ti APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURRWrGPATlgS.It" �'-/�q/DLf Re-roofs _
Signatturd ol'ApplicanuCamusecter Oak
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
f J
Will the applicant or to[=building oaupamemm or handle hamomes material
u defined by Ne Cupanin.Municipal Code,Chapter 9.13,and the Health sed Safety
ode.Section 35532(¢)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or were building occupant esu equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air eontaminants as defined by the Bay Area Air Quality Mmagormen all new materials for inspection.
7.I.DburDistrict? rrYes
1 have mad the hamnlous materials requiremems under Chapter 6.95 of the Califor.
HealthA,SaftyCode,ScNans 25505.35533 and 35534.1 understood that ifthc building
cs not cuemly haw a emant Nat it is my responsibility m entry the meopent of the
uimmcm an teem�pd&n14117 acertfic
.4 afNv9/ y Signature of Applicant Date
Ownar .car a hori'rcd egem �"'F a I Date All roof coverings to be Class "B"or better
" Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
- CITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS: ILl
S / PERMIT # 650,/d
OWNER'S NAME: f}A)L) PHONE6,3/ -8Z1YC1
GENERAL CONTRACTOR: FAX # 3/- 84/
I am not using any subcontractors: (c , (Z Gc O f/ OS /9 O
LI
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
�
Owner/Contra-Ator Signature Da e
10/28/03
CITY OF CUPERTINO
WATER HEATER
OF
CUPETI� INO PERMIT APPLICATION FORM
APN# r3 / / ^ _ ( � _ Date `
Building Address: U/ �� t5/ -7 1 L6
Owner's Name: a � i � °`— a ` P q0 . —
Contractor: Phone: �" 9(/ License
. #: �/-
HOT WATER. INC. -�3('8�� 7&3G a-
Contact: INDUSTRIAL
ALF O D 94070 Phone: Cupertino Business Li ense#:
SAN
5f3 � �
Building Permit Info:
Bldg ❑ Elect ❑ Plumb L4' Mech ❑
Job Description: , \
w
Residential Commercial ❑
i
Cost of Project:
• Strapped El On Platform ❑ Bgnded ❑
New Location ❑ Re placement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMTI'FEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING