03080140 CITY OF CUPERTINO ?- «r b-JI0 � •+
BUILDING DIVISION PERMIT CONTRACTQR INT'ORMATION
t BUILDING ADDRESS: HOT WATER INC PERMITNO03080140
4ESTBRN 9R
AM I. . 2531 GRACELAND AVE PERMIT ISSUEDATE
JNE: SANITARY Op NO.
(650) 298-8494
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMBMECH
100
LICENSEDCONTRACTOR
under
DECLARATION Job Description
F ❑ I hereby affirm than 1 am fths, u under provisions ofChapterCode. 9(commencingsis p
�W with Section 7000)ofDivixion Sof Ne Business and Professions Code.and myliccnuis
nfaumraandclr 7G3 t'Z REPLACE WATER HEATER
3=_
=_ License I,ry Lie.Y '
yDare U ARCHITECTS DECLARATIONws � — q
AeiI understand my plans shall Muud as public remail.
U
SodLicenud professor.]
g Oat I am exempt
from
DECLARATION I�
e 4 I Masa .Sect than 1 oro exempt from the Comms Co Any c Law far the VG%
00 following uireu a Section t 7onstr Business and improve.
de Professions Code Any tiny or county C
$ which rcyuires a pctmil In construct,alms imprnvc,Jcmnlixh,or repair any structure
'?yy prior to its issuance,also requires the applicant for such permit o Glc a signed statement
2sp that he is licensed pursuant to the Provisions or the Contractor'sLicenseaw(Chapter9 Sq.Ft.Floor Area �� Valuaho
2 (commencing with Station 7 )of Division 3 of the Business and Professions Code)or
y that he is exempt thciefmm and the basis far the alleged esempnim,Any violation of a
Section 703 l S by any applicant for a permit subjects the applicant to a civil penally of APN Number QGGD &IIC Type
not more m
than e hundred delta,$($500). - - -- -- P Y -.
❑I,ss owner of the property,or my employees with wages as their sole compensation,
will do the wars,and the structure is not intended or offered for sale(Sec.7044,Business 502 — FINAL p.T
and Professions Code:The Contractors License Law does not apply m an owner of � IINPcffiMERGY
prupeny who builds or improves Nemon,and who does such work himselfer through his 506 - GAS TEST
own employees,provided that such improvements ace not intended or offered for sale.If.
however,the budding or improvement is mid within one year of completion,lite owner- 507 — FINAL PLUMBING
builder will new the burden of proving Nat be did not build or improve fat purpose of
sale.).
❑'I,as owner of the property,am exclusively contracting with licensed contractors to -
construct Ne Ironical(See.7044,Business and Professions Coda:)The Connotes'Li-
cense Law does not apply to an owner or property who builds or improves thereon.and, _
who contracts for such projects with a contractor(s)licensed pursuant to the Conrames
License Law.
I am exempt under Sec. B&P C for this moon
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby alarm under penally of perjury one of the following deblaradons:
I here and will maintain a Certificate of Consent to self boure for Worker's Camper.
1C%33 '
on,as provided for by Section 3700 of the labor Code,for the performance of the
rk for which this permit is issued.
have and will maintain Worker's Compensation Ins amosec,as required by Section
of Ne Labor Code,for Ne performance of Ne work for which Nis Permit is issued.
Workers pelnsatin InTsurance Cartier end Policy t�ttmber amer. Corn�1~I�C 1`-`V SJ[J Policy NoT V ZC) f�)
CERTIFICATE OF EXEMPTION FROM WOR ERSW61(a�t c]/
COMPENSATION INSURANCE �(M
(Thisuction need notMcompleted if the Permit is forma hundred dollars(SIttB
nr less.)
1 cenify that in the performance of Ne work for which this Permit is issued,1 shall rot
employ any person in any manner so as to became subjecno the Woraux l7 mprnsanion
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If,after making this Cenificale of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
= O forthwith comply with such provisions of this permit shall be deemed revoked.
ti N CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the Performance of
Ya > the work for which this pcomit is issued(Sec.3097,Civ.C.)
YQ Under's Name
D ,z Larder's Address _
J Q 1 certify that 1 have read this application and stem ordinances
the above ws relating is
]. F building 1 agree to comply with all city and county ntativ s Of and stem laws relating to
JU building construction,tinerentl heuhyauthoprposeumatives of this city to enter upon the
W ahavc(We)spun
sopa save,
for inspection ntrifakeep ha.
ti Q0 (Wu)agree to save,indemnify and kith hay in an the City of Cupertino id City
rh in consequence
of thebostsang of this es Permit, may in any way accrue against mid City
',[� A APPLICANT
of UNDERSTANDS
this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGU Issued by: Date
.ATy��NS.
l C I2/g/p�
Signemre of Applia =LDr HAZARDOUS MATERIALS DISCLOSURE Dam Type of Roof
Will the aPPliearl tar future building Occupant store or handle haxaNws material
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the Heal lit and Safety
cde.
osOYas zss3xan - nNa All roofs shall be inspected prior to any roofing material being installed.
Will 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
7dc�
aeardous air contaminants az defined by the Bay Arca Air Quality Management all new materials for Inspection.
❑Yes ❑NuIh&Safetave mad thchmalloonsus 2555.255ls ui ad 2554.1undnts under hrstooapsord.9t ifthof eCaldingoW&Safety Codc.Sccdons 25305.25537 and 25534.IundcrslanJ thatifthc buildingot currcn0y havea tenant,Nat it is my rsponsibility to notify the ncupant ofme
mc hl-hmostbeion dor toissuanceofaCcnificateofOce dr. Signature of Applicant Date
� owr or authorized Dare All roof coverings to be Class "B"or better
CITY OF CUPERTINO
WATER HEATER 3
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
� UPJ z� G3
Building Address:
s1 GJS%Fz z,✓ ��
Owner's Name: Ph ne#:
/—��20 b�,.�so N �l0£�� 3' 783Y
Contractor: .Phon cense
Contact: Phon Cupertino Business License #:
61/-/(?/S G����r �aSd�
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ,Il> Mech ❑
Job Description:
Residential R Commercial ❑
Cost of Project: c�J
Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replacement(c)
QtY .
l Ca le Fee ID Fee Description Fee Grou
BPWHEATER Water Heater/Vent BUILDING.
PPERMITFEE PlumbingPermit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING