04050061 ° CITY OF CUPERTINO -�-' � '� •�' ° "' "" .".'Irzi ?ni
a BUILDING DIVISION PERMIT COi1VTRACTORIINFOR ATION
eu1LDINGADDRESS: ALL VALLEY PLUMBING PERMIT NO 04050061
r44 TOT-TM nR
OWNER'S NAME: PERMIT ISSUE DATE
30NE: SANITARY NO. CONTROL NO.
(510) 376-4816
I
CHITECf7ENGiNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm Wet I am licensed under pro ons of Chagas 9(commencing Job Description
inSeetion7o�ya fDivision3of�e9 oars hoommsCode.andmyhe..1,
`u0`° REPLACE WATER HEATER
Z License Clm Lk.p `
Dau 1;Ganlnacmr !.' 1 3 J
I AR i1TECTS DECLARATION 1 11 II,
I understand my plans shall W used u public mcords
i0 Licensedacreby onel " II
OWNER-BUILDER DECLARATION
0 I Wehy.(sere that 1 1. exempt from the Contamml License Law for tin
m 0 which
reason.(Saban 7(O mo Business and ..d rinm Code:Any city m aunty
$ which Ryuises a Permit m cnnsuuee clue W prove,demulbh,nr repair any stmctum
FZS° Pnormiuiensedp pursuant
Me provisions
visio so Me Co permiuoiense La dsuumem
Womme(commencing
wJ pursuant m We of Disi°m of We Commas Licenumon Chodtm9 Sq.Ft. FIOOT Area Valuation
B
met
exempt Section 70W)of Division3 M thened Business and Professions Ctionof
Nel ha b tamps therefrom end Uu bub for We alleged exemption.Any violation of
Section 7031.5 by&M applicant for a permit subjects tha applicant o a civil Penalty of 3GLIM3xD"erO0 Occupancy Type
not mart Wan five hundred delta.
❑I,as Corer of We property,or my employees with wages u their sole compenssdon,
willdo Wework.and the NumYR lsnolinunded orofBod forsele(Sec.7044,Buinw Required Inspections
and Profesdans nt
Cade:The Corecmrs License law docs and a e apply an owner of q P
propenywho wildsorimproves Memo,and wh.doesiuch wmkhimselfarlNCugh his
man employees provided that such improvements art notinended mortared fossae.If.
however,We Wilding or improvement is sold within as year of impletion.We owner-
builder will Tuve We burden of proving that M did not Wild or improve for purpose of
sale.),
O I.as owner of the property,am exclusively contracting with licensed contrsnors to
constmat We project(Sm.7044,Business and Professions Code:)The Conhaemr's Li.
cense law docs not apply to an owner of property who Wilds or imProvu Manor.and,
who contracts for such projects with a conuacea(s)licensed puuuanuo the Conuecmb
License Law.
0 l am exempt under Sec. ,B As P C for this reason
Owner Dau
WORKERS COMPENSATION DECLARATION
J 1 hereby affum under penalty of perjury one of We following declarations:
-„/ I have and will mountain•Cmdfiesu of Consent to¢If-insure for Warka'i Compm- '
sstion,ss provided for by Section 7700 of We IsWr Code,for dm performance of the
work for which Wis permit is issued.
❑1 have and will maintain Workers Compensation Insurance,u required by Section
3700 of the Labor Code.for We performance of Me work for which his permh is issued,
My.Worke' Componsotion hurunna timerand Pio numWrme:
6� rnr� x Na,: 16 53?16 2 03
CERTIFICATE OF EKEMPIION FROM WORKERS'
COMPENSATION INSURANCE
(This section need it lacomplmW time permit is f Crane hundred dollars(SIM) f
or Icer.)
1 anify that In the performance of We work for which this permit is issued,l shall not
employ any person in any meanerse as in become subject to Oe Warkers Compt n.tion
Laws of California.Dae
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Eacreption,you should
become subject to We Workeer's Compensation provisions of We Labor Code,you mus
OZ fnMwith comply with such provisions or this permit shall W damcd revoked.
Z OCONSTRUCTION LENDING AGENCY
)-w Iherthy affirm that More is a ansuuction ending agency for We penurneana of
a We work for which Wu permit b issued(Sec.3077,Civ.C.)
Igl Q landcfs Name
g' z Landers Addauss
U0 1 anify Wn 1 have Rad Wis application and sum Wu the strove Information b '
F correct I ages,to comply with all city and county ordinances and sou law relating to
CU building construction.and hereby auWonm representatives of this city to enter upon the
R7 above-mentioned Properly for inspection purposes
gy (We)ogee a ass°,indemnify and kap harmless the City of Cupertino against
rn Ilabilitieejudgments,coats and expenses which may In anyway ecc=against Wd City
U Z incomesecnceofthegantin of Wispeonit.
APPLICANT D WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC ULATIONS.
Re-roofs
ignsummof ApplianUCommenor Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tie applicant or future Wilding occupant more orhandle haandUes material
ss defined by We Cupertino Municipal Code,Chapter 9.13,and the NcaIW and Safety
otic.satiea zss3z(an All roofs shall be inspected prior to an roofing material being Installed.
❑rue �Nn P P Y g g
Will the applicant m fmure building aaupam tax equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
roll hazardous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes W71u
1 have read the harardonsmaurialsrtquimments under CluPurh93 tide Wilding
ria HglN BSafct 33s03.2SA3 and 2S314.1 understand thutime Wilding
doss trot corm y hew a unapt t it b my responsibility a notify We Occupant of c
equle hoh most heren poi r w Worknee of a Cenificae of Occu.ncy. Signature of Applicant Date
6
Owner or authorized agent Dom All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
f Cupertino CA 95014
Telephone(408)777-3228
ICI w Fax(408)777-3333
UPER.TINO
Building Department
JOB ADDRESS PERMIT#
f0"f� a u
OWNER'S NAME: , F2 PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
66 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 ( a
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
r/Contractor lgnatiire t
CITY OF CUPERTINO
WATER HEATER o /
CUPERTINO PERMIT APPLICATION FORM
APN# d D Date:�� 1c
J
Building Address:
Owner's Na e: 7 / Phone#:
!
Ida-, GJ�u V �-r L& ca
Co trac or: Phone: License#:
Cont a t: Fhone: Cupertino Business License#:
YinAL 6
D
Building Permit Inf :
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project:
Strapped On Platform 0 Bonded ❑
New Location ❑ Replacement
tyif
li ab e Fee ID Fee Description Fee Group
B WHEATER Water Heater/Vent BUILDING
ERMITFEE Plumbin.g Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING