05010132 (2) CITY OF CUPER7'[NOi
BUILDING DIVISION PERMIT CONTRACTOR INI ORMATIQN ?.
DUILDI NO ADDRESS: WATER HEATERS ONLY PERMIT N905010132
OWNER'S NAME: PERMIT ISSUE DATE
6KENNETH FRI D 01/24/2005
ONE: SANITARY NO. CONTROL NO.
800) 835-5946
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
j 00 LICENSED CONTRACTOR'S DECLARATION Job De 10 O O O
I�'+ 1 ion 7 .form that 1 em licensed unser provisions as Chapter 9(commencing [�Q . As Wm
i
with 5 I there y effort that I am licensed index pr Foremasts Code a9(my license comommems 'aryl 1�fs�`�,IfI'(/`/(/.Yp\� ta]�"_J'
s<�
in farce and trial. " -7 T.t -1 REPLACE WATER HEATER
?M? Dacte�� Cunt.nor
e ARCHITECTS DECLARA
L lundcmans my plans shellWusedaspuhlic rtcnrJs 2 n
005
y6 FEBCt] a a. o
ya LiccnreJPmfcssirnel tg�1�}pt®tatt
OWNER-BUILDER DECLARATION �� r, ®tlII �7
f 1 Wrchy air.mat 1 am exempt from the Contractors License Law for the unl�
COO (allowing recon.(Salon 7(131.5,Business and Pvfcuinr Cock:Any city r county
$ which re'don,a permit sat construct alter,improve,demolish.or repair any,srmUce 0 0 0
Prior to its issuance,also require,the applicant for such Permiu0 file a signed statement
that he i0censed Pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft, Floor Area Valuation
� $ (commencing with Section 7")of Division 3 o the Business and Professions Code)or '
y 33
at he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant In a civil Penalty of
.at more 0n hundred della.(6500). Q Occupancy Type
re N
❑I,as owner of the property,.my employco wish wages as their sole compensation,
will do the work,and Ne structure is not Intended or olremd for ale(Sec.70".Business
and Pmre.mn,Cade The Conuxmr',Lt..Law does not apply to an owner of Required Inspections
property who builds orimpraves thereon,and who does such work himself or mmugh his
own employcw,provided mateuch orgeme anno are not intended mo0esed for sada It .
however,the building or improvement IZ WId whereas year areomPletme.me ewhat'
Wilder will ban Ne human of Proving that W did not Wild or Improv for purpose of .
..to I
❑I.as owner of Ne properly.am exclusively contracting wit licensed contractors to
cottact Ne project(Sec.7(104,Business and Professions Cotler)The Contracted U:
Gere law dm,not apply to an owner of progeny who Wilds or improve thereon.and,
who contracts for such projects with a com uctor(s)licensed pu.umt to the ohmmeteM1
License law.
❑1 sm mempl under Sec. .B&P C for Ni,mason
Owner Due
WORKER'S COMPENSATION DECLARATION
1 hereby&Man under penally of perjury ane of shoe following daearatiotu:
I hon and will mainuin•Conifiate ofC..m..](.Iran.for Workers Cempen. ,
cation,u provided for by Sestion 3700 of the Labra Code,for Ne performance of me
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700 or the Labor Code.far the performance of the work for which this permit is issued
My Worker,Compensation Insurance artier and Policy number art:
earn.: S t. 0.-• Policy N..;55_0'50 a 4 1 1
CERTIFICATE OF FXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need mK W completed lrme Tomtit 1,rnrane hundred delta.(SIM)
Ices.)
I certify mat In the performance of the work for which Nb Permit is Word,I shell not
employ any person in any morn,so as in Waome,ubjecuo she Workcri Compensation
Laws of C.lif..o.Dow
Applicant
NOTICE TO APPLICANT:If.after making this Continents of Exemption,you should
Wcome aobject m the Worker.Compensation provisions of the labor Code,you..at .
=O forthwith comply with such provisions or this icrmitat.11 be deemed revoked,
r0 CONSTRUCTION LENDING AGENCY
I hereby alRrm that mem i,a contraction lending agency far me performa.e,of
Y.� the work far which this permit Is issued(See.3097,Civ.C.)
A Lender's Name
73. Q Lender's Address
:.)Q I«nify that I haus mad this application and tote that the above information is
j U bonding I agree m comply With sal city and county ordinances of and sate laws r upon don
imoveng a firoom P."Iyhereby ocumn'repreumatisp of this city to enter upon don
aWm(We)are to save for daspity an keep ea /yam
(Wc)agree t,about indemnify and keep Meme. w City or against against
Tq in cosegenceofthe granting expereawhtch may In my way accmc against saio City "'OJ
J
APPLICANT UNDERSTANDShe granting or IAND WILL COMPLY WITH ALL NON-POINT Issued by: Date /^
SOURCEREGU
-�� &N1 o S Re-roofs
Signawrc of Appliarac tractor Dam
HA ARDOUS MATERIALS DISCLOSURE Type of Roof ,
Will the applicant or furore building occupant store or handle hazardous material
as dcflncd by the Cupertino Municipal Code,Chapter 9.12.end the Health and Safety
ale.Section zss3z(a)7 All roofs shall be inspected prior to any roofing material being installed.
Will me applicant or future Wilding occupant use equipment or dcvia,which If a roof is Installed without first obtaining an inspection,I agree to remove
it harardous sit comamin is u Jcfned by the Bay Arta Air Quality Management all new materials for inspection.
n7
❑Ya
I he.retd the ha..doo,materials requirement under Chapter 6.95 of the Califor.
iia Health&Safely Code.Sections 23305.25533 arni 25534.1 unrkr,unal mat if she Wilding
dos not currently Iron a tenant that It i,my responsibility he notify the occupant of the
reyuim uwhic esu metpdorm' enao(aCcniOauof rangy, Signature ofApplicant
rizeJ age Date Date
All roof coverings to be Class"B"or better
Owner ter aulho
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
Cl OF Fax(408)777-3333
IOUPERTINO
Building De artment
JOB ADDRESS: ,2-0 (0 8 � � PERMIT v 5 o 1 U 1 3 2
OWNER'S NAME: Q PHONE # 4q .2,-7
GENERAL CONTRACTOR: -Q- FAX #
I am not using any subcontractors: T�Q. W,.Wjj� - \z'f, ea V>� /Zy'OS
ignature 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
�jTile
Owner/Contractor Signature Date
CITY OF CUPERTINO
WATER HEATER o Polo 0 25--
CUPEkTINO PERMIT APPLICATION FORM
APN# 3 / -5- 0 0 Z
J C S
Building Address: ZDV F (1
Owner's Name: /� Phone#: ` ,'
Contractor:1Da&.c) /�J 4 � hone�00 $35-S 9�i 6 License#: ,2) -7y S 7 3
Contact: IV hone: Cupertino Business License#:
S9
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: 5u aw
Residenti Commercial ❑
Cost of Project:
Strapped On Platform Bonded El
New Location ❑ Re lacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMTTFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING