03070218 (ARCIflTT:CVENG.INCHR:
OF CUPERTINO :dna ro .�'t'' -+ ' `•�'%
,Dlnc Drvlslory - Pi✓RMIT CONTRACGnR INFORMATION :
Or)l 7 RAMPART AV
But
OWNERS
ORLON TERRY G AND CLAIRE V PERMIT b003070218
NAME: PEIaMRISSIfE DATE
LOW TERRY G AND CLAIRE__V_ 07/29/ 003
SANITARY NO. CONTROL NO.
CVENOINEER; BUILDING PERMIT INFO
BLOG ELECT PLUMB MUCH
LICENSED CONIBACI'OR'S DECLARATIONreby affirm Thal l am licensed under provisions of Chapter 9(commencing JobDescriptFI�K .An7M ))ad Division 3 ofthe Business and Professions Code,and my license isrr •�V■ �®nured and effect.
jIjZ LicenseClas. Lk.N WATER HEATER REPLACEMENT
iNp Dale Cunlr ECL AUG O 2003
e 7W ARCHITECTS DECLARATION 17 4 O C W
`1 U I once ruaod my plans shall he used as public records _
s ii Licensed Professional811�LD�NG
OWNER-BUILDER DECLARATION
I 1 hereby affirm thm I am exempt from the Cnnlnctor's License Law for the
OO following reason.(Section 7031.5.Business and Pmfessiom Code:Any city or county
<S which requires a permit in construct.alter,improve,dcmnlish,or repair any structure
°i!^ prion,,its issuance.also requires the applicant for such permit U Nc a signed Statement
That he is lice road punuant to the provisions of the Contractors License Law(Chapter 9 Sq. Ft. Floor Area Valuation
2 0 (cum memos,wi in Section 700f)c(Divoion 3 of the Business and Prufcsdnns Code)ur
y
that he is exempt therefrom and the buts for the alleged exemption.Any violation of 36926043 . 00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of APN Number Occupancy Type
not mom Nan five hundred dollars(5500).
❑1.u owner of the property,or my employees with wages u their mole compensation,
will do the work,and the structure is not intended or offered for sole(Sm.7064,Business b02 — -I = c
and Professions Code:The Conuacto's License law does not apply to an owner of 506 —. GAS T
property who hullds or improves themon,and who doessuch work himself or through his
own employees,provided that such improvements arc nor intended or offered for ask,If, 507 — FINAL PLUMBING
however,the building or improvement is sold within one yem of completion.Ne owner-
builder will have the burden of proving that he did ant build or impro a for purpose of
sale.),
❑1,as owner of the property,am exclusively contracting with licensed contractors to -
construct the project(See.7044,Busincu and Pmfessiona Code)The Contractors Li.
cense Law docs not apply to an owner of property who builds or improves themon,and
who contracts for such projects with a contvmm(s)licensed pursuant to the Contractor's
License Law. -
❑14M
exempt on e e. B k P C forth' mason
Own
WORKERS COMPENSATION riOem
DEC Care
7037. I hereby aBlrm under penalty of perjury one of the following declarations:
"l
ave and will maintain a Cen ricate or Consent to sel0insure for Worker's Cumpen.
,m provided for by Section 3700 of the Loiter Code,for the perfnsmance of the
for which this permit is issued
ave and will maintain Worker's Compensation Insurance,as required by Section
of Ne labor Cade,for the performance o(the work for which Nis Permit is issued.
orker's ComPeuatiun Insurance carrier and Policy number art:
r: Polity No.: _
CERTIFICATE OF EKEMMON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed Urine permit is fnronc hundred dollars($11%1)
less.)
1 certify that in the perrnrmanee of the work for which this permit is issued,I shall not
employ any person in any manner so or to become subject o the Workcri Compcnsalion
Laws of California.Due
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption.you should
become$Object to the Worker's Compensation previsions or the labor Cnde,you mum
7 O forthwith comply with such provisions or Nis Permitahall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
1 hereby anion that Neff is a construction lending agency for the Performance of
Y the work(lir which this permit is Wood(Sec.IDB],Civ.C.)
yQ Leaders Name
3 Z Lenders Address
JC) I certify Net I haw read this application and cute that the shout information is
y correct.I agree to comply with all city and county ordinances and aide laws miming to
'U building convection,and hereby amhorim representatives or his city to enter upon the
�CS1 'how-meniumed property for inspection purposes. -!.
4 G (Wo)agree to save,indemnify and keep harmless the Ci ly of Cupertino against
4 h fell lilies,Judgments.costs and expenses which may in any way accrue against mid City
UZ in consequence of the limns of this permit.
^' APPLICANT UNDERS O NO WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU
P` 701 Re-roofs
Sk tore of App anu Comou'lor ale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant lir future Wilding occupant store or handle havmdous material
m defined by the Cupertino Municipal Code.Chapter 9.17.and the Health and Safety
Cal c.Section 75532(a)7 All roofs shall be inspected prior to any roofing.material being installed.
❑YesNa
Wilt the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hamrdnus air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
i5VIC17
❑Yes �Nu
I have mad the havardnus materials requirements under Chapter 6.95 of the Cali for.
ria HealthA Safety Code,Soon no 25505,25533 and 25534.1 undcraund that ifthe building y
Jots not curtemly how e u ,then' is my rupansihllhy m nndl'y M acuponl of the
mqu' entswhi- et I toiuvance r.Composed d. Signature of Applicant Date
All roof coverings to be Class "B" or better
Own�nrcJ aFcnt Date
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform:
A. ZAll the work authorized by this permit
B. _ A portion of the work
C. _ None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. A portion bf,the work (complete section below)
Contractor Address/City. Phone # State License # Type of work to
be performed
3. _ 1 will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer(see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
performed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information(reverse side
Property Owner's Signature: // Date: ? Q�
job Address: Permit# 6 ✓
Any changes to the information provided on this form shall be submitted to the=ofuno Build
• Devartment.
CITY OF CUPERTINO
WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN# f Date:
Building Address: 0
r
Owner's Name: Phone#:
Contractor: v �) ;'/�, delx Phone: License#:
Contact: — Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ . Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project:
Strapped On latform Bonded El
New Location ElRe laceme
Qty
A i ble Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING