03090026 CITY OF CUPEIITINO
BUILDING DIVISION PERMIT `CONTRACTOR INFORMATION ;
.4...at.@v_0t,. ��A?L_..a E '3•'�w. ✓ "'.<'"3ynsr _
BUILDI GADDRESS: HOT WATER INC PERMIT"0 3 0 9 0 0 2 6
WNER'S NAME: 2531 GRACELAND AVE PERMIT ISSUE DAIS
°NEi (650) 298-8494 SANRARYNO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
306 LICENSED CONTRACTOR'S DECLARATION j Job Description
I hereby affirm that I am licensed under provisions of Chapter 9(commcndng t
with Section TOM)of Division 3 ofdtc Businus and Professions Cade,and my license is
O in full forcono £t T� r�y,T.{"
:8 z ueenre cle (-Le.g 'TER E U
e`p Dam
Contractor DECL `
LuS�j
ARC CTS OECL RA O I.1 r t
y l undcmand my plains shall6,used a path 4`cords -� f litl -•� r ```1,1,Ut~^^�\\\,M\
°p Licensed Professional '
OWNER-BUILDER DEC TlO/f 1
I 1 hcrcby oRrm Net 1 am eacmpl(um die nbrxi LiQh \ t he
❑O following mann.(Section]1171.5,Business end Pro funs Cnoe: citIy
S$E which requires a permit to conuruct.alar,improve, ,Peds ���777au any strunute
pro,In its tauance.ithurcqutrcs lheapplieam forsuc de asigned statement
aY that he is licensed pursuant the provisions of the Contractors License law(chapter9 SCI. Ft. Floor Area Valuation
2F (commencing with Section 7")of Division 7 of the Business and Profesainns Code)tar
Nat he Is exempt thcmfmm and the buts for the alleged exemption,Any vtoladon a( 37502011 . 00
Section 7031.5 by any applicant for a permit ubjects the applicant to a civil penalty of APN Number Occupancy Type
not mart than five hundred dol4n($500).
1,as owner of the propcny,or my employes with wages as Neo role rompensadon.
will do Ne work,and the structure is nor intended or offered fonale(Ses.ID44,Busircas 1U6 — SEWERionsgg pp__�
and Professions Cod,:The Contravenes Licence law docs not apply to an owner or 2 0 2 - UNDERFL(JOR PLUMtt ING
property who builds or improsva thereon.and who dues such work himself or through his
own employees,provided Nat such improvements art not intended or offered for can.If. 301 — ROUGH PLUMBING
however,the building Or improvement is sold within one year of completion,Ne owner.
Gilder will have the compact of proving that he did not build or improve for purpose of 302 — TUB & OR SHOWER
.ICJ. 502 - FINAL PLUMBING_ ENERGY
❑1.Car Owner of the property,me exclusively contracting with licensed canouctar:Io 5O6 — GAS TEST
construct the project(Sec.7044,Business and Prefesims Code:)The Conteri Li-
cense Law does not apply on an Owner of property who buiMm or imyroves Income,and, 507 — FINAL PLUMBING
who corset,for such projects with a coract am)licensed pursuant to dr Contractors
License Law.
❑l am exempt under See. ,B&PC for this moon
er Dao
WORKER'S COMPENSATION DECLARATION
1 hereby MBsm under penalty of perjury one of the following dedaa0ons:
1 have and will maintain a Ccolfrcaa of Continuo sel6insum for Workers Compact.
cation,an provided for by Section 7700 of the labor Code,for the performace of the _
work for which this permit is issued.
QO(
ave and will maintain Waken Compensation Insurace,u required by Section
the labor Code,for the performance of the work for which do.permit 4 issued.
My Workers Compe,nss.a-d�o�n Insurance carrier and Policy num
Coria:�TITIrG I"VN'7 Policy No.: �L/�
CERTIFICATE OF MEMPfION FROM WORKERS
COMPENSATION INSURANCE
(Thissceto.reed not hec unneted if the permit 4 fmonc hooded dollars(SIM)
or teas)
1 easily Nat in the performance of the work for which this Permit 4 issued.l mall not
employ any person in any manner so as to become subject to to Workers'Compensation
Laws of California.Dao
Applicant
NOTICE TO APPLICANT:IL afar making this Ccnificate of Exemption,you should
become subject to the Workers Compensation previsions of the Lahr Cade,you mat
70 forthwith comply with such provisions or this permit shall be domed invoked.
ti 0 CONSTRUCTION LENDING AGENCY
1 bi from that Nee ire a construction lending agenry for de,Pe,panne star
x r7 the walk fur which them permit Is issued(Sec.3W7,Civ.C.)
1)0lander':Name
3. z Lenders Address
J I certify that 1 have read this application and stem dust dm above information is
.y correct,I.gran to comply wit all city and county ondinancef and Cute laws relating to
building caamlrtrCIfi a,and hereby authorise misesenutivn or this city to enter upon the
above-memiuned pmpcny fm inspecdan purposes.
ti gy (We)agree to save,tndcmniry and loop harmless the City of Cupertino against
Tn liabilities,judgments,costs and expense:which may in any way¢crue against aid City (�
J 2 in consequence of th,granting of this Permit.
t"t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REG TI - O
l D
SigneluSignatureoM IicaO Data, Re-roofs
HAZARD1
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant nt tar fume building n Chapter
stem or handle Health a materia)
u deRned by ons Cupertino Municipal Code.Ch.pmr 9.12.and the Health and Safety
Section 255724)? All roofs shall be inspected prior to any roofing material being installed.
❑Yu Ya
Will the applicant or future buildingacupant use equipment Or devices which If a roof is installed without first obtaining an inspection,l agree to remove
emit aesrdoua oil ccataminmu u dcdn,d by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yom
I have mW the hasardt`ms mateaa4mqutremenCs took,Chapter 6.95 of Che Califor.
nia HcaW&Safety Cedc,Sections 25505.25533 and 25534.1 understand that if the building
dao not cumcru y ham nest,Nat it 4 my map mihility m nndfy 1M amup t of da
re timmena whir I t an`�``�vwnkeo acertifi„tear Oc, Signature of Applicant Date
9 kg 1 a All roof coverings to be Class"B”or better
Owner a, gem �—
CITY OF CUPERTINO
m 8 of 8 PERMIT RECEIPT OPERATOR: euem
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37502011.00
DATE ISSUED. . . . . . . : 09/03/2003
RECEIPT #. . . . . . . . . : 23003
REFERENCE ID # . . . : 03090026
SITE ADDRESS . . . . . : 10141 CRAFT DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : YEE MELVIN
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : SAN JOSE CA, CA 95128-3422
RECEIVED FROM . . . . : HOT WATER INC
CONTRACTOR . . . . . . . : GUSLANI, CHRIS LIC # 21311
COMPANY . . . . . . . . . . : HOT WATER INC
ADDRESS . . . . . . . . . . : 2531 GRACELAND AVE
CITY/STATE/ZIP . . . : SAN CARLOS, CA 94070
• TELEPHONE . . . . . . . . : (650) 298-8494
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW SAL
__________ _____________ __________ __________ __________ __________ __________
BENERGY PERMIT FEE 1.00 23.10 0.00 23.10 0.00
BPWHEATER PER HEATER 1.00 9.99 0.00 9.99 0.00,
PPERMITFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00
TOTAL PERMIT 68.61 0.00 68.61 0.00
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ------------ ----__-___________
CHECK 548.88 7158
------------
TOTAL RECEIPT 548.88
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
03 01
CITY OF CUPERTINO
WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN# 2 f 6 6 Date: U3
Building Address: J
01 C'� �y ,�z
Owner's Name: Pho
ole L,91 Ft ray �
Contractor: Phon : L ense#:
/ o� r,�/.1 3� S c Cs) t GJ 6 2
Contact: Phone �.. Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project: Cki
Uv
StrappedLi On Platform ❑ Bonded ❑
New Location ❑ Re lacemen
Qty. if
AppliV'qb�e Fee ID Fee Description Fee Group
BPWHEATER Water Heater/ Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING