05030226 CITY OF CUPERTINO ='
BUILDING DIVISION PERMIT ¢CONTRACT�ORINFb MAGI p.
RUILDINGADDRESS: WATER HEATERS ONLY PERMrrNO05030226
Ow NEWS NAME: PERMIT ISSUE DATE
ONE:
SANTIy RY 6WROL NO.
ARCHITEC AINGINEER: BUILDING PERMIT INFO
r8LDG ELECT PLUMB MECH
u0C LICENSED CONTRACTOR'S DECLARATION
��
I1 hereby affirm that I am licensed ander provudOw,of Chapter 9(commencing Job Description ,
ias with Section7")of Division 3 or shc Business and Professions Code,and my license is
n<a in full tome and eff�tARCH '
�'q_ Liccrseaass uc.g REPLACE WATER HEATER 90,�
^Fqp Deese CSDECr
I understand my plans shall be used u public retards U ✓
3u.G Licensed Professional
3 OWNER-BUILDER DECLARATION
S I hereby affirm that I amI.S.exempt from Ne fContractors C License Law
y. for tW
D o following mason.(Section]BJ 1. Business end Professkns Code:My city or county
$ which myuims a Permit to Wrea the
tlter.l run such
h oNiN,are sig any swnure
priormits�ensed c,nsumyuins the inion of far suchperniuo tilt asignedstaomem
L'Z<
�f$ that Wcncinnsetl Seed..mtWproviviovnfthe of0.BactorsndPoullLaw(Chapkr9 Sq. Ft. Floor Area Vahiatio
(commcncin8 with$cnion]OOo)af Division Jo(thc eusincisantl Profrssiaru GMc)or
that he is exempt thrafrom and the basis for she alleged exemption.My violation of
Section 7031.5 by airy applicant for a permit objects the applicant in a civil penalty of 3��ro 0 Occupancy
ams mora than five hundred dollars($5011). P Y Type
❑I.ssowner of the propmy,Omy cmploycu with wgexsstheir sok rompensstion,
will do the work,and rheswcam is not intended molfered formic(Sec.]BU,Business
and Professions Cade:The Conmcors Liceno law door not apply to an owner of Required Inspections
progeny who Wilds or improvnthefeon.and whodoessuchwmk Monodic,through his
ownemployeeu,provided dmsuch improvemens are notimended or offered for We.if,
however,the building or improvement is sold within one year of completion,the owner,
builder will have the burden of proving Net he did not Wild or improve for purpose of
sak.).
❑1,as Owner of the progeny.am exclusively contracting wish licensed contractors in
construct Ne project(Sec.7044,Business and Professions Code:)The Contractor's Li-
ve Law does not apply as an owner of property who Wilds or improves thereon.and
who contracts for such projects with a conations)licensed pursuant to the ConuacsoYa
Lt..Law. ,
❑1 am exempt under Sec. .B&P C for Nis mama
Owner Data
WORKERS COMPENSATION DECLARATION
1 hereby affirm under poorly.(,do,aro of the following deelaradmu:
1 ha¢and will maintain a Certifiam of Convent to self-insure for Wonkeri Compen.
amen,as provided for by Section 3]00 of the Labor Code,for the performance of she
work for which this permit is issued.
have and will maintain Wofkeh Compensation Insurance,as required by Section
of the Labor Code.for the performmec of the work for which this permit is issued.
My Workers Com ado Inslu�ma artier and Policy neumb�er art:
Cartier. ~-` Polity No.:y��0µ'�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This session mcd nothecomplems]if the Permit Is Forane hundred dollars(SIM)
or less.)
1 certify that in dre performance of thc work for which this Permit is issued.I shall not
employ any person in my mmnerm as k become subject to the WorkOfi Compensation
Laws of Calif nnia.Date
Applicant '
NOTICE TO APPLICANT:If,ager making this Certificate of Eaccrption.you should
bec.me subject in the Worku's Con counr on provisions or the Labor Code,you mus
0z rundowns comply with such provisions or this permitm.11 W decmetl mwkcd.
O CONSTRUCTION LENDING AGENCY
Thereby Mr.that Nero is a emuuucsinn lerdin for the rfmmanaof
thega.) p
Z' Le work fur which the permit is issued(Sec.3097,Civ.C.)
a 0 Lenders Nmnc
=Z lender's Add.
V p 1 ttnify that I have mad this application and sure Nat the a Wvc udommtiun k
L4 F correct.I agree to comply with all city and county ordinances and arose laws relating m
�(J building construction,and hereby authonoc representatives of Nu city to moor upon tW
aWvcmenuoxd propertycosts
for inspection purposes
0. (We)agree to save,indemnify and keep harmless the City of Cupertino against
Z liabmscaNene of lboSoar and of thisexperaos mit. may in my way accrue againstsudCity
V z A APPLICANT
of UNDERSTANDS
Souring of this permit Issued by: Date
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON-POINT
SOURCESOURCE REGULATI�
25�D5 Re-roofs
Signature of ApplitanVCanuacmr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will rhe applicant of future building mXUpantatom or handle haionfous material
as defined by the Cupertino Municipal Code.Chapor 9.12.and the Health and Safety
L'adc.ga40n 25532(x)7❑Ya -^"" All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building accupam use equipment or cicvim which If a roof is installed without first obtaining an inspection,I agree to remove
r 1,bah dnus air comeminanu as defined by the Bay Area Air Quality Management all new materials for inspection.
❑Yes
1 have mad Ne hvardous maodals m9uken cru under Chapter 6.95 of the Califor-
mulHeshh&SafetyCade.Sections 255115.255]3 and 25534.1umkneand dretifthe Wilding
docs mol curcndy hint a kan4 16at it k my rosponsihility m madly the ac ant of Nc
rtyuimmcnu
both
met pnorwiss cola Ccrtificao ofa
Signature of Applicant Date
Owner ser authon'rcd aFOwner or ,�o5�G5 All roof coverings to be Class„B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY Of Fax(408)777-3333
�UPEI�TINO
Building De artment /
JOB ADDRESS: `033 -7 /vwr�u �* !. PERMIT # CTb 2 ° L 2-
OWNER'S
OWNER'S NAME: aw. PHONE # ;L &J -7 - 0t3S
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:In7 owes �,v"'"`� - y/3a1o5
Signature T— 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 .
e 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 CUPERTINO /
' WATER HEATER 0S"� 3 ° Z 2 E�
CUPEI�TINO PERMIT APPLICATION FORM
APN# 3 rj — ! v 3 T Date: 31
Building Address: 1 0 3 3 7
Owner's Name: A Phone#:
A-4190L --�-4/ 7- v 2s
Contractor: ' 1 p _/) one: License#:
Vo
LCJa C.W �a�CPao e3,5 - 59t( 3 45 73
Contact: o✓ Phone: Q Cupertinousiess License#:
Building Permit Info: I�
Bldg ❑ Elect ❑ Plumb,116 Mech ❑
Job Description: A', _ �� .,
Residential Commercial ❑
Cost of Project: i
gao
Strapped El On Platform ❑ Bonded ❑
New Location ❑ Re lacemen�
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
/ BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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