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07010120 CITY OF CUPERTINO BUILDi NG DIVISION PERMIT �1 Its T�R IQ1N* BUILDING ADDRESS: PERMIT NO. 10228 COLD HARBOR AV AFFORDABLE OWNER'S NAME: PERMIT ISSUE DATE DOROTHY BROUGHAM 24707 SkN FERNANDO RD 01/19/2007 SANITARY NO. CONTROL NO. ONE: (661) 259-7131 BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH 0 0 JOOO LICENSED CONTRACTOR'S DECLARATION ,lob Description �m 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing _.z with Section 7000)of Division 3 of the Business and Professions Code,and my license is REPLACE WATER HEATER y in full force and effec 1 ` j n? License Class LIC. A E o Datc Conlractar r ' ARCHITECTS DECLARATION a< I understand my plans shall be used as public record DyU r.4 U.r~„ Licensed Professional OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the 00 following reason.(Section 7031.5,Business and Professions Code:Any city or county K m which requires a permit to construct,alter,improve,demolish,or repair any structure Z y prior est its issuance,also requires the applicant for such permit to file a signed statement Valuation a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $1500 2=0 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or Z. that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 36909037 . q Number Occupancy Type not more than five hundred dollars($500). ❑1,as owner of the property.or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale.If, however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon,and, who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. ❑1 am exempt under Sec. B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compcn- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Worker Compe-ns-aation ImLyrance carrier and Policy number are: Carrier: �� /�f� _PolicyNo.: 'O(C) i� CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is foronc hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued.I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Workers Compensation provisions of the Labor Code,you must Oforthwith comply with such provisions or this permit shall be deemed revoked. Z , CONSTRUCTION LENDING AGENCY ►�-� I hereby affirm that there is a construction lending agency for the performance of p+ > the work for which this permit is issued(Sec.3097,Civ.C.) Cw Q Lender's Name Lender's Address U 0 1 certify that I have read this application and state that the above information is V. correct.1 agree to comply with all city and county ordinances and state laws relating to CDUbuilding construction,and hereby authorise representatives of this city to enter upon the W above-mentioned property for inspection purposes. G4 (We)agree to save,indemnify and keep harmless the City of Cupertino against rn liabilities,judgments,costs and expenses which may in any way accrue against said City V Z in consequence of the granting of this permit. Date APPLICANT UNDERST NDS AND WILL COMPLY WITH ALL NON-POINT Issued b:r: SOURCE REGULATION . t� 7 Re-roofs Signature of Applic Contractor Date AZARDOUS MATERIALS DISCLOSURE Type of:Zoof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Code,Section 25532(a)? �,t All roof:.shall be inspected prior to any roofing material being installed. C3 Yes ywo Will a roof is installed without first obtaining an inspection,I agree to remove ll the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes [ Vo 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building does not currently have a tenant,that it is my responsibility to notify the occupant of the requirements which must beme priorto issyancc of a certificate of Occupancy. Signator' Applicant Date f , lq -07 y All roof coverings to be Class"B"or better Owner or authofi-zed a Date Community Development `-, 10300 Torre Avenue a{ Cupertino CA 95014 al Telephone(408)777-3228 MCITY OF Fax(408)777-3333 ''UPERTINO Buildin De artment JOB ADDRESS: PERMIT # 10 4.ak CAI 4a/-k�, PVA - OWNER'S NAME: Dor6qq PHONE # 0 - d 3 - (001 c1, - GENERAL CONTRACTOR: FAX# I am not using any subcontractors: `L- Signature Date Please check applicable subcontractors and com Tete thefollowin information: 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 Tile Owner/Contractor Signature Date CITY OF CUPERTIN O OqDl 01� WATER HEATER CUPE[�TINO PERMIT APPLICATION FORM APN# Date: 1-0 - 07 Building Address: Phone#: Owner's Name: 40k- Contractor: Phony: ��( License#: '� - 1to�-� X310�' ab e aler �(�T2�s a i 3 ) Cu ertino Business License#: Contact: Phony;: b 1 I p C� l� cow Li1T1 �.F�ela 5 • o�au Building Permit Info: Bldg ❑ Elect ❑ Plumb d Mech ❑ Job Description: ---------------------- Residential Commercial ❑ 2 Uee q C - 1 1 0 cc S 2��'e� - S cAMe I OCAri bre = (�c��a��_ Cost of Project: I b U Strapped On Platform Bonded ❑ New Location ❑ Replacement Qty. if Fee Group Applicable Fee ID Fee Description BPWHEATER Water Heater/Vent BUILDING PPERNIITFEE Plumbin Permit Issuance PLUMBING BENERGY Energ BUILDING BUSLIC Business License BUILDING