07020007 CITE'OF CUPERTINO
BUILDING DIVISION PERMIT TSR 1
BUIL INGADDRESS: PERMIT NO.
0833 NORTHFIELD SQ. WAGNER, KATHY 07020007
PERMIT ISSUE DATE
OWNER'S NAME:
WAGNER, KATHY 02/02/2007
SANITARY NO. CONTROL NO.
,HONE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
i
00 LICENSED CONTRACTOR'S DECLARATION Job Description
vI hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of thc Business and Professions Code,and myli=psc is TANKLE S 3 WATER HEATER
y in full force and a fecL 01
n z License C! Lic•#
t p Date C
ARCHITECTS DECLARATION
7 g< I understand my plans shall be used as public records
)aU
e
U.y Licensed Professional
< OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
COO following reason.(Section 7031.5,Business and Professions Code:Any city or county
$ which requires a permit to construct.alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
:s 0 that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $400
r t— (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i 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 Number Occupancy Type
not more than five hundred dollars(5500). 2 04080 0 3
❑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 Trot 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.
❑I am exempt under Sec. B&P C for this reason
OwnerDate
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 Car Worker's Compen-
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 Warker s Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Chis section need not be completed if the permit is formic 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 an manner so to bcc c the Workers'Compenstation
Laws of Califomi
Applicant
NOTICE TO A ,a r making this Certificate of Exemption,you should
become subject c Wor s Compensation provisions of the Labor Code,you must
0 forthwith comply with sue or/;
or this permit shall be deemed revoked.
Z° CONSTRUCTION LENDING AGENCY
V) I hereby affirm that there is a construction lending agency for the performance of
r7 the work for which this permit is issued(Set:.3097,Civ.C.)
QLender's Name
a Lender's Address
U 0 I certify that I have read this application and state that the above information is
LL, correct.1 agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
r/) liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
�+ APPLICANT NDERSTA S AND WILL COMPLY WITH ALL NON-POINT Issued by
SO ULATI
Re roofs
P7HA
ZARDOUS MATERIALS DISCLOSURE - Pate Type of I:OOf
Will theant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cotte,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes /.�
L N.
If a roof s installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
-emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.I understand that if the building
docs not curmn y have a Lena at it is my responsibility to notil'y the occupant of the
rcqu' n is m t riortoissuanceofaCertificateat cup ey. Signature of Applicant Date
All roof coverings to be Class"B"or better
r authorized c t Datc
CITY OF CU
PERTINO 0q02000-7
WATER HEATER
CUPCITYEt�TINO PERMIT APPLICATION FORM
APN# 3J(0 _3 7 -.063O Date: .
Building Address:
Owner's NN -E Phone#:
2A6 -6
Co tractor. Phone: License#:Co �
Contact: Phon': Cupertino Business License#:
Building Permit Info:
-Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description•
Residential Commercial ❑
Cost of Project: rva
Strapped ❑ On Platform ❑ ` Bonded ❑
New Location ❑ Replacement
Qty. if Fee Group
A lic f Fee ID Fee Description
BPWHEATER Water Heater/Vent BUILDING
j PPERNVIITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING