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COF CUPERTINO
BUILDING DIVISION PERMIT
t1RITY
�COIVTRAC'�INFORMA.T.IQN
BUILDING ADDRESS:
TOM s S PLUMBING
PERMIT "0-05120113
OWNER'S NAME:
PERMIT ISSUE DATE
NED BANTON
12246 S
19/2005
NE:
SANITARY NO. CONTROL NO.
(408)867-6010
ARCHITEC IENGINEEN:
BUILDING PERMIT INFO
ELECT PLUMB MECH
= O O
LICENSED CONTRACnderp DECLARATION
Job Descri u
1 ion:that am Ilaosed under of Chapter 9 (commencing
p
with Section 00) of a and Profession is
of Divides 3 of to Buinwand ProfeWuu Car,and my license b
Rod �'1
uanmC ;n°^f�`L (o
REPLACE WATER HEATER Q1
Lm.��t
Dade
Jag
j��-S DEC ATI 1
I understand my plain shell h Editor
Ie, mcnrN
,sem
Lrenssd Profceaionel
Oat I am cUILDER DECLARATION
I barony law for IN
aRinn that I sin exempt from the Cssimas Any
following memo
mem Co : c
703L4 Business and Pm(essinos Code: Any city stcounty
eroullt Iso sig
which )equinane, me
C 87,rj
alsoMUIMthe,alcor,
forIndemolish,
a siny gned statement
prior LLI ILL IYYfiMp, also mGabG BIc epions o (ver each permll bice s eLaw (Chapt ¢al
fammhe r (Chapter
Sq. Ft. Floor Area
Valuation
inSwitpurwmt7000)ofDiviaosoftheheBodemrtandPrscesdo
(commencingwith Section viCak)m
of the Budmsemdon.
r and ft basis for Any of
ted Any
aluminum and the bur far Ne alleged eanmant
-3 APM F
Occupancy Type
it penalty
by any applicant for a permit subjects the applicant a dvll penalty ^!
io 31.5 b to
Section
choun
not mom thin Ove hundred dollars ($SW).
0 I. as owner of the property, or my amplayces with wage as their sole compensstion.
'
will do the works and the mucime is not intended or offend for sale (Sec. 7044, Bosirwxa
Required Inspections
and Professions Cade, The Conmmoh Licenses Law dna not apply m an owner of
e q p
property who builds her Improve thercon.and who doesauchworkhimee f int rough his
awn employees. provided that such Improvements ars n^tinu:nded maimed foraela If,
however, the building of improvement issold within ane year of completion, Ne owner -
builder will have the burden of proving that he did rut Wild or improve fur purpose of
sale.).
❑ 1, an owner of the proRrty, am exclusively convening with Baued convenors to
,
wmdruct the project (Sec. 7044, Business end Profession Code:) The Contractor's Li•
acus law Jeri not apply to an owner of property who Wilda or improve diseases, and
who contracts for such projects with a contrscter(O licensed pursuant in the, Contractors
License Law.
❑ lamexempeunact See ,Bi PCforlhisraem
Owner4 Due
WORKER'S COMPENSATION DECLARATION
I hereby &Ran under penalty of perjury ane of the fallowing dalentiau:
1 have and will maintain aCertifiaes ofcomem be self -Imam fmwo lecescampen-
satlon, as provided for by Section 3700 of Ne labor Cade, for the perf^rmum of the
work for which this permit is issued.
0 1 new and will maintain Worker's Compeosation Insurance, a inquired by Section
37W a( the tabor Cade, fm the performance of the work for which this permit is issued.
My Worker's Compensation Inuarence carrier and Policy number sin:
f, �s
Carder. 1 AI.yJ� f9a r Policy No.: C 6 1 � �7 "f /
CERn CATE OFFXEMPIION FROM WORKERS
COMPENSATION INSURANCE
IThr section need natio completed lithe (omit Is foranehundred dollars (Slot)
or less.)
,
I artily that in the p almmanm of the work for which this Permit is issaed, l [hall not
employ anyperson in my manner an as m becomesubject to the Warkeri Compensation
Laws of California. Dam
Applicant
NOTICE TO APPUCANr: If. after making this CeniBam of Exemption, you should
become subject 70 tha Worker's Compensation provisions of Ne labor Code, you most
forthwith comply with such PmvWaos or this permit hall be da and coveted.
CONSTRUCTION LENDING AGENCY
I Mosby of . used tem Iso mnsvmtimt knding agency for the Pedarron. of
the work for which this permit 4 bound (Sec. 3097, Civ, C.)
Lender's Name
Lender's Addreo
1 certify thal l haw (rad this application sed mm dor use show information 4
cancra I Agra to comply with all city and county ordinances and auta laws relating to
building convection, and hereby suthadm mpmaemative of Nis city to enter upon the
above-mentioned Property for Inspection purposes.
(We,) agra to taw, indemnify and kap bartnla the City of Cupertino against
liabilities, judgments, amts and expenses which may In any way accrue against said City
)
in of die mating of this
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
ysW CMR 12. 6f/�
S umAppbaDam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or (alum Wilding me score or handle material
Heardoos
u Cupertino by the Cupeno Municipal Cade, Chapter 9.13, and the Health and Safety
Chapter
Cam, section 25533(8)7
❑Yes Na
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicmt or alum Willing aaupam use equipment m °)vias which
It hazardous air contsminants u deRad by usm Bay Ares Air Quality Management
all new materials for inspection.
iufict7
❑Yea [yNo
1 hew mad de hazardouamemdals requirements underChamer6.95 of the Califor-
nr. Health &SalnyCede, Sovaw 25505,35533 aa125334.l unticmmd tin ifft Wining
Jae not currently haw a mnm6 that 4 my responsibility be natty than mcwam or the
requirements which gBWmm � issumeo( a Cart�gly1 pyo
' o/1 �JDam
Signature of Applicant Date
All roof coverings to be Class T" or better
Owner '
authoed&Sent
•
t
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS: /
'Lo ZZ D Not— 1r
PERMIT #
_/2-0//2
OWNER'S NAME: Al-,(
PHONE # -AS 2 —66 2 Z
GENERAL CONTRACTOR
FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
Owner/Contractor Signature
Date
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
V/
Plumbing
S
zdeplftl
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature
Date
,
CRY UP
CUPERTINO
t
CITY OF CUPERTINO 2 0 VWATER HEATER �S
PERMIT APPLICATION FORM
APN #
Water Heater / Vent
Date:
2 -
Building Address:
Plumbing Permit Issuance
PLUMBING
Owner's Nam
Energy
Phone #:
CoI ctor:� n
Phone:
96-7
License #:
181�
S r'
Contact:
Phone:
Cupertino Business License #:
S --dl 6 Lla .
oDb
Building PoWnit Info:
Bldg ❑ Elect Ca'
Plumb
Mech C'
Job Description:
w
Residential ❑3( Commercial ❑
Cost of Project: U �1 S o
Strapped On Platform LJ
Bonded El
New Location ❑ Replacement
1Z
Qty. if
FAP nPcrrintinn
Fee Grout)
BPWHEATER
Water Heater / Vent
BUILDING
PPE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING
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