03120074 CI'T'Y OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: HOT WATER INC PERMITNO.03120074
OWNER'S NAME: PERMIT ISSUE DATE
— NE: SANITARY N0, CONTROL NO.
AR CHITECrIENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MEEK
Inc, LICENSED CONTRACTOR'S DECLARATION
�w❑ I herehy affirm that I am licensed under provisions of Chapter 9(commencing Job Description
iW with Section 101111).rDivision3afth.0usinessand Profoaturn Code. dmy license is
r`oh in m0 line and gre fP 2 REPLACE WATER HEATER
j 2 Liccnx Lk.N a1p��� G�Ap®p/�� ®
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dy RCHITELTS
DECLARATION
C e�
'� a 1 undcrvmJ�}Y�tans a us d as public records
.1/
any LicenuJPmfc l"�s' FEB 1 3 2004
OWNER-BUILDS DECLARATION
<� 1 hereby affirm that I am exempt from the Contractor's License Law for the
p0 following munn.(Scenon1f13IS.Business and Pmfcssions CWC:Any city or county �®�
K m which requires a Permit nr construct.alter,improve.demolish,or repair any structure
priocto its Moore..all.rcyuiruthe applicant for such permit to f It.signed statement
Ezp
(native isliccnudpursuanttoNcpmvisiomofis,Contraclor'slJct.Law(Cloilum9 Sq. Ft. Floor Area Valuation
At (commencing with Section 7")of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and Of basis for the alleged caemption.Any violation of
Section 1031.5 by any applicant for a Perit subjects the applicant to a civil penalty of 3 1`I�k'I9(➢�ei 0 0 Occupancy Type
mot more than five handrea dollars(SSW). P Y YP
I,u owner of the property.or my employees with wages u their sole compensation,
will do Ne work,and the,waren is not brooded ocoltered for sal.(Sec.1014,Business
And Professions Coe:The Conlsactor's License taw does not apply w an owner of Required Inspections
property who builds or improves thereon,and who doessuch work himself orthrough his
own employers,provided that such improvements An,not intended or offered for sale.If,
however,the building or improvement is sold within on year of completion.the owner.
builder will have the burden of proving that M did not Wild or improve for in rpeu of
oats.).
❑1,a owner of the propeny,am exclusively contracting with licensed eoetraaors to
construct Ne project(see 7W,Business and Prefcalwas Coe:)The Conmetsi Li-
cense Law does not apply to an owner of property who Wilds or improves themon,and
who contracts for such pr*cu with a eonsactor(U licensed pursuant to but Contractors
License Law,
❑1 am eaempt under Seo. ,B N:P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 heroby affirm under penalty of perjury one of the following declarations: .
I have and will maintain a Certificate of Consent self-insure fur Worker'sCompen-
sation,as provided for by Section 37M of the labor Coc,for the performance of N.
wmk for which Of,pc.is is issued.
❑1 have and will maintain Worker's Compensadon Insurance,as required by Section
3180 of the labor Code,for the Performance of the work for which this permit is issued.
My Worker's m nsatio Insurance carrier and Policy numbcLam:
Carrier. Ue Poliq No.:_L/(-1LC(�(L/•sJ![I//K2_
cE TIFICA OF"IcIAMON FROM WORKERS'
COMPENSATION INSURANCE
(ITU section recd not W completed if the permit is fnronc hundred dollars($100)
or less.)
I cenify Nat in the performance of the work for which this permit is issued,1 shall of
employ any person in any manner u as to become subject o the Workeri Compemafion
Law,of California.Data
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Eacmption,you should
boome subject to the workers Compensation provisions of the tabor Coe.you must
., 0 forthwith comply with such provisions or this Permit shot)he deemed rovokcd.
ZC7 CONSTRUCTION LENDING AGENCY
[— l hcmhy affirm that there is a construction lending agency for the performance of
C' the.,it for which this permit is issued(See 31091,Co.C.)
�W Q Lenders Name,
J Z Lender's Address
U Q 1 comfy Nat 1 have mad thin application and sum that the above information is
D. (~ cannot.1 agree o comply with all city and county ordinances and tram laws relating to
QU above-menniong red properly
hereby authorimmpree.nbtima of this city to enact upon the
Y' C. ahovcmce)agre to saw fodcmniftion laceir es
(We,)agree to use,and expenses
and kith hart in An the y so ro Cupcnst agairm
FO2 inconsc6jogmcnts,costsandOf this
may in anyway accrvc against said City
U z APPLICANTc UNDEf Oc RSTANDS
of this permit. / � /�
APPLICANTTGGUHDNLLDq7E1RSTANDS AND WILL COMPLY WITH A1,L NON-POINT Issued by: Date
SOURCE trTGHI.AJ'IONS.� ` 1 _ /
I 'X�` � �'�1\ /UlrlL Re-roofs
Sdgna pplmadiConnaaor Dao
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum Wilding nccupam store or handle ha mous maorial
u defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
CW..Screen 23s3z(aY.a All roofs shall be inspected prior to any roofing material being installed.
❑Yu
If a roof is installed without first obtaining inspection,I agree to remove
Will the Applicant Of fwum Willing acupam u¢equipment of devices which g an ins P
it hoaardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
triet3
❑Yes d]Ny
I have read the haurdous Materials reyuircments under Chapter 6.95 of the Califon
7doe,f
Health 6 Safety Code,Sodom 25505.25533 and 25534.1 understand Nu ifthe Wilding
not currently have alcram.that il'u my r.sponsihilily w nodfy IW ucceP1m of the
vircPmnt� hich meal be pfiorwissuance of Ccrtihcate of cp Signature of Applicant Date
I Q _" �
Owner Ara thhon,vag� "--Z' Date All roof coverings to be Class "B"or better
CITY OF CUPERTINO
z1a WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN # 3(,o o2 o 0 D 507 12—
1 Z 1 01x3
Building Address: b
7 9
Owner's Name: I Phone #:
w vt (ArGtm6ty (gP31 255-/L101
Cont acto"r: Phone: License #:
Contact: Phone: Cu ertino Business License-i—.
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ill
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential Commercial (❑ f
Cost of Project: soo
Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replacement
Qty 'f
A lic ble Fee ID Fee Description Fee Group
BPWHEATER Water Heater/ Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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