03070116 1 n CITY OF CUPERTINO �'*r .:� sssrd' �:4", '� `• •
BUILDING DIVISION PERMIT ACO,N4TRAC OR TNF0RMA�TTO.N '.
BUILDING ADDRESS: WATER HEATERS ONLY PERMIT No 03070116
10364 CARMEN P.QAT)
OWNER'S NAME: 970 E. MAIN ST, SUITE 200 PERMIT ISUH DATE
ONE' (800) 835-5946 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
ZZ 0 0 0 0
LOp LICENSED CONTRACTOR'S DECLARATION Job Description
I hcrchy efrum thu I am licensed under provisions of Chapter 9(commencing
n� with S.OmTglsn.f Divisio 3of Oe BusiAaSx ofcwov ie. ylicens ®`
in full fnse and R�ltt.3 a ■ IN .tl� 16=®
��b License Clas} a LACE GAS WATER HEATER ,MPS
z- Das d contractor
ARCHITECTS DECLARATION 2003 r��
N l undeutarid my plans rill he Suu mc
Sued public..oil.
NOV '1 O
7
3 G 1 Licensed Pmfcesinntl
3 OWNER-BUILDER DECLARATION
RATION
00 I hcrchy.(fere that I em exempt from Ne Ctsium, o :Anyc I,rw for the BUILDING p o which ng ream..(Section 8131.5.Business and sue de inns Code:Any city structure rounty L�/
$ which its iss s n permit n const he else improve,demmiN,lire a sir any uawme
Ftprior p+
Out he
incensed e.alSO uantto rertWvision of for men
urcum'soleete Lawdsutemem
z�ss< (comorireingWdpurwanTOthe M)of Division 3 or the Buusminimnslaw(ChapterCode)or Sq. Ft.Floor Area Valuation
(comms..xempt therefrom
and
Division nrtWegedAss and opem.An professions Crbc)ur
$ Nat he h exempt th.efrom and Ne bests for the alleged eumption.Any violation of 35709087 . 00
Section 7031.5 by any applicant for.permit Subjects the applicant to a civil penalty of APN Number Occupancy Type
nos more than five hundred dollen(S500).
❑1,AS owner of the property,ar my employees with wages At their role eompenSallon, �3T�7]u7p��T
will do the work,and the anchor is not intended or offered for S.le(Sec.7016,Business _ rPLW(e6WRC T7R
and Profcuiona Code:The Ormommes Limns law docs trot apply to an owner of 506 - GAS TES W(e6'M3Pe YY
property who builds m improv thereon,and who does such work himulf or through his
mean employees,provided Nat such improvements are not intended or offered far ale.If. 507 - FINAL PLUMBING
however,the building or improvement is sold within one year of completion.the ower.
Wilder will have She burden of moving that he did Out Wild or improve for purpou of
ASIA.)
.
❑L AS owner of the property,am exclusively concocting with licensed contractors to
msutruct the pmject(See.lite,Business and Professions Code:)The Contractors L).
cove Law door not apply to an manna of property who Wilds or improv themon,and
who concocts for such projects with a contactor(,)licensed pursuant in the Con ri
Ucenu Wan.
❑I am exempt under Sec. ,B As P C for this reason
Own. Das
WORKER'S COMPENSATION DECLARATION
1 herebyeffimt under penalty of perjury one of the fallowing daclaratimus:
1 have and will maintain.Cenirrene of Consent to calf-intim for Wmrkees Compere
1037.�)Iffl
ion,m provided for by Section 3700 M Ne labor Code,for On performance of the
rk for which Nil permit is issued.
Hove and will maintain Worker's Compensation Insurance,v required by Section
or the labor Code,for the performance of the work for which this permit is issued.
Warkerk Compensation Insunnm eerticr and Policy numher art:
rtier. Policy No.: _
CERTIFICATE OF EXEM PITON FROM WORKERS'
COMPENSATION INSURANCE
(Thu uetion need not W completed lithe permit is for one hundred dollus(SIM)
lir less.)
I ecnify that in the performance of she work for which this permit is issued,I Shall not -
employ any perun In any manner so is In Wmmmubjecuo the Worker,'Cnmpensadou
Laws of California,Das
Applicant
NOTICE TO APPLICANT:If,After making this Cenirrces of Exemption,you should
become subject to the Worker's Compensation provisions of the Ichor Code,you must
.JO forthwith comply with such provisions or this permit Modred.
hall W Accrued reed.
Z"� CONSTRUCTION LENDING AGENCY
r
[-� I hcrchyafrnm Nthereits constructionlending atcncy IM the perrmmmcc lir
C theLe de work for which this peermit Is lured(See.309],Civ.C.)
Le
WM Q nders Name
F7 z Lenders Address
U Q 1 ecnify that 1 have read this application and rete Net She above information 0
L4 F cortin.I agree to comply with all city and county ordinances and State law raising to
0 building construction,and hereby tuthodu mpewmativ of this city to enter upon the
:i.a above-mentioned pmpcny for inspection purposes.
(We)agree to save,indemnify and keep hermleu the City of Cupertino against
rex liabilities,judgments.costs and espenus which may in any any acme against Said City
(„)7 in cnnuqucncc of Nc g ting of Chir O rani
'7 APPLICANT UND TANDS D COMP WITFyALL NON-POINT Issued by: Date
SOURCERECU /I
Re-roofs
Signature of Applic,WComrutor Das
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding mccupmt store or handle hmardous material
At de0ned by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code,Section 25532(s)t All roofs shall be inspected prior to an roofing material bei. Installed.
❑Yoe ❑Nm P P Y g 8
Will the applicant or future Wilding occupant use equipment or deviate which If a roof is installed without first obtaining an inspection,I agree to remove,
it hewrdnu.air cnnuminents AS defined by the Bey Arca Air Quality Management all new materials for inspection.
Now,?
p Yes 0 N
I have mad the WraNrmsmasdHs requirements under Chepur6.95 of Ne Carlow.
m end Heft AtSafm,Code,Secuum 25505,25533 25534.1undculmd that lithe Wilding
does not currently hem a mlima Our It is csponsOili y m lino ly the occupant of the
mgmimments wnicn be met r mar (aiBeaewomup.n Signature of Applicant Date
--
Owner or am -. All roof coverings to be Class "B"or better
,dud eFmnl Dmc
07/15/2003 20: 32 5105303202 LEGALITIES INK PAGE 00
DM X0LD
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CITY OF CUPERTINO
"i 1c. }ril Et
CUPEf�TINO PI RMIT APPLICATION FORM
APN# Date:
5
Building Address:
Owner's Name: Phon G '10� mss�G it
Con�t�tc 9, --,,��// Phone: License #:
G% lY� Sg 274k-3001 ,3 7y573
Contact i Phone: Cupertino Business License#:
Building Permit
Bld ❑ Elect !In Plumb
Mech ❑
Job Description:
aur. I 0a,
Residential ?Commercial ❑
Gost of Project: 0 :
2 Oe
7apped ❑ On Platforma. Bonded El
i ,
New Location ❑ Replaceent>c
Qty. if
Applicable Fee 1D.. 't. . Fee Description Fee Group
/ BP.WHEATER .',i Water Heater/Vent BUILDING
PPERMITFEE Plurbin Permit Issuance PLUMBING
BENERGY Ener BUILDING
BUSLIC . Business License BUILDING
2 �. ��