05030178 CITY OF CUPERTINO + '"
BUILDING DIVISION PERMIT CONTRA.CTOR�INFORMATION ig
Put ADDRESS: SPEEDY ROOTER PLUMBING PERMIT NO.05030178
aOWNER'S NAME: PERMIT ISSUE DATE
TNFS
ONE:
SANITARY IYe 1 OL NO.
t
ARCHREC,ENGINEER: BUILDING PERMIT INFO
J BLDG ELECT PLUMB MECH
+O+Oo LICENSED CONTRACTOR'S DECLARATION //
C I Mreby affirm that I am licensed under provisions of Chapter 9(commencing Job Description �,
U with Section'IOf1U)of Divisio 3 offt Business and Profcuians Code.and my license,is
_cm infmllmayand err«t.e 36 Zcj �/�/ / _ REPLACE WATER HEATER 4A 111s:A®
O$z Date se
C'y��Canuactor C '1Oka
nFp Dale, y /a
ty ARCHITECTS DECLARATION
1 undersand my plans shill W used as public record; I\/(/J/lp�q ��"✓
JyU /v/
C Lkcnud Pmfcssionel
3 OWNER-BUILDER DECLARATION As
00 I hereby affirm Nal 1 1. exempt from Ne GOmUmclora License Law for IW
p o which following Permit
oto construct.
Business and mprow,nsium h.or Any city Of county
K$ which rcyuims a permit oc bouton,altos.Improve,demolish,orrepairpair any tangcwr
poor miu issuance.also mquiru the applicant for such Permit flcasigned starcmcm
that he is licensed pursuant m the provisions of thd Contnatur's License Law(Chapter YSq.Ft. Floor Area �Val'uaton
tor$ (commencing with Section 7000)of Division of the Business and Professions Coast)or
_ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicam for a permit subjects one applicant to a civil Penalty of 3 gyf}tll�yerp p Occupancy Type
not more Nan fire hundred dollars($5007.
❑I,as owner of the progeny.or my employees with waguas their role eompenvuon,
will do Newark,and Neswnom istur's Lndcdo Lwit faros apPa.90 a4,Budnw Required Inspections
and Rty,wh ou Cade:TW Conuxeara Liaise law dans not apply to an rough is q P
propertywasa,provi improveschimpr and who dasauchwork oroffredthrough his
own employees,provided that sato rat is mid wit in not car of tl mpleered farathe owner.however.the building orimprovementisalee within one year of completion,Neowners
builds will nave d¢burden of proving Nu W did not Wild or improve for purya¢of
❑1,as owner of the property.am exclusively contracting with licensed contractors to
concoct the project(Sec.7144,Business and Profusions Cade:)The Contractor's Li.
cense Law docs not apply to an owner of progeny who Wilds or improves theron,and.
who concocts for such projects with acomautor(s)beem ed pursuant in the Conaactoes
License Law.
1 oro exempt under See. .B h P C for this reason
Owner Dale
1M37WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ons of the fallowing declarations:
1 have and will maintain a Certificate of Consent to self-iuumforWorker'sCompen-
ion,u provided for by Section 3VW of dm Labor Code,far dre performance of the
rk for which this permit is issued.
1 have and will maintain Worker's CompensationInsurance,as myuird by Section
W of thlathe bor Code,far e performance of the work far which Nis permit is issued.
y Workers CCompensation Insurance carrier and Policy number am:
rtim Il2��-V Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thusection section,W completed if tW permit is forane hundred dollars($I WI
or less) ,
1 eenifv that in the performance of the work for which this permit if issued,I shall not
employ any person in any manner so as in become subject m the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate or Exemption,you should
become subject of the Wmkch Comp nscorm provisions of Ne Labor Cnde,you most
.,O forthwith comply with such provisions or Nis permit shalt W deemed revoked.
Z " CONSTRUCTION LENDING AGENCY
[-.� I hereby alfrm that them is a construction Lending agency(or the performatim of
CL the work for which this permit is issued(Sec.3W7,Civ.C.)
[[]Q L endo',Name
Lender's Add.
U 0 1 anee n c 1 have roti this city
and county
and some thn the aWs<cos relating 10
0 F building I ogre to comply with all city and coumy oNinas¢o and suss Taws riming m
V idbovenmentioned construction,and hcrnyamM1onprrcises. tivcs of Niscinymcnrr upon Nc
r[!7 aMve(We)are to acrysave for iuunify a purposes. 1
(We,)agree to cove,indemnify and keep f` haw City of Cupertino against /s/Y h liabilitiu,judgmcnts,toss and cap..wnicM1 mery in in m any waYamuc against to City
U Z in cnmse eafthcgmn' gof ' permit. _
^ APPLI UNDERS N ILL COMPLY WITH ALL NON-POINT Issued by: Date 3 D
5 U GULAD S
i � ?`7-05� Re-roofs
Si mumof Applicarol onracmr Dam
HAZARDOUS MA RIALS DISCLOSURE Type of Roof
Will the applicant or future buil gmcupantsmrcorhandlcha Wousmaterial
as defined by the Cupertino Municipal Code.Chapter 9.13,and the HcalO and Safety
Cmk.Section 25532(x)7 / All roofs shall be inspected prior to any roofing material being installed.
[D Y. BNo
Will the applicant or future building xcupant esu equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Distric@
❑Yes f}Dlu"
ve read he th mit materials rdyvirmanu under Chapter 6.95 of the Calif.,
ria &Safety Code- ctiou 0505,25533 and 25534.1 undersand Wl ifthc Wilding
J ' ,surtendy ha ten ti,u rsponsinilitytondily the acuPart of the
'ra whiten at once nn ccolfeate of Occupmey. Signature of Applicant Dale
—� 7 0 _ All roof coverings to be Class"B"or better
caner or authotlrcd agent Date
Community Development
10300 Torre Avenue
!t Y Cupertino CA 95014
*. Telephone(408)777-3228
CITYFax(408)777-3333
\ �,UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT # 8S�
/d// 6 /- -27/7S/T- S 6
OWNER'S NAME: JOS/ ,*7AIG S' PHONE #
GENERAL CONTRACTOR: o7FG� FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followinginformation:
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
ile
Owner/Contractor S ature Date
CITY OF CUPERTINO oS 3
t - WATER HEATER �'
CUPERTINO PERMIT APPLICATION FORM _
APN # �,7 ,Z D / Z Date:
-/ 7- 0 S
Building Address: C
/D//6 LSP L
Owner's Name: Phone #:
J ��n/ �AiivFs
Contractor: Phone: License
d5P�&v 110,07T;-79- cro8- 7y6 _8/ f35 7oy33
Contact: Phone: Cupertino Business License#:
lzrc�2 - yDgg
_ 7YB , / 8 `�
Building Permit Info:
Bld ._ ❑ .- Elect_❑ Plumi-a' Mech ❑
Job Description: p _
Residentiat-R� Commercial ❑
Cost of Project: 13
a0
Strapped On PlatformLL4' Bonded"-❑'-"" - - --- '
New Location ❑ Replacement El
- Qty. if _ ----_._. ._. - -^--
A licable Fee ID T' ""=�=- Fee Descri tion " I Fee Group
BPWHEATER Water Heater/ Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
/ BENERGY Energy BUILDING '
BUSLIC Business License BUILDING
17
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