05030145 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAC�TiJRINFORMATION ;:
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BUILDING HOT WATER INC PERMIT ND 05030145
nT!Tj CT
OWNER'S NAME: PERNAD ISSUE DATE
ONE: SANITARY O. CONTROL NO,
(650) 298-2494
ARCHITEC MNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u_Op LICENSED CONTRACrOR'S DECLARATION
I hemby affirm that 1 am Handed under provialoaz of Chapter 9(mmmcmpng Job Description
I with Section 7003)of Division 3 of Ne Business and Profession Code,andmy license is
inmllform deif« `WATER HEATER REPLACEMENT
za�z Liccvc Cl Lk.N
r Data "nox
ARCIMCCC1S DECl_XRXr1ON
91 1 i mdcrsund my plans shall W used u public acemm
DiU
3 ta0 G Licensed Professional
5 OWNER-BUILDER DECLARATION
.� f 1 hereby affirm drat 1 am exempt from the ConlrumYs License Law for the
❑O following mason.(Section AD 1.5,Business and Professions Coda:Any city or county
S:
S t' which requires is permit to construct,eller,improve,demulm1b.or repair any structure
Fz< prior to its issuance.able rcquins the applicant for such permit to fila a signed statement
Z s O that he is licensed pursuantto the provisions of the Contractor's License law(Chapter 9 Sq.Ft.Floor Area Valuation
mh$ (commencing with Section?000)of Division 3 of thea Business and Professions Code)of
_ that he is exempt the¢fmm and t e basis for the alleged exemption.My violation of
Smdon?031.5 by any applicant for a Permit aubjccu de applimat W a civil penaltya( 3 9I4'�.Ulrffier0 0 Occupancy e
not more than fins hundred dollars($500). P y Typ
❑1,m ower of Ne pmpwy,or my employe"with wages u deG mlc comprnudun.
willdothework.andtheswcwmunotintendedaofferedformatel ec.?Os/,Bob
and Professions.Code:The Contractors License law docs not apply m an owne or ; Required Inspections
property who Wilds.improwa thermn.and whodassuch workhe"O' a' ug pis
own employees.provided that such improwmenes are not installed oroRemd for
however,the building or improvement is sold within rem:year of completion,the
builder will have the burden of proving that he did not build or improv fm pis 'of
"ley
C]1,u owner of tW pamp try.am cisclusiwly contracting with licensed con q al - ✓ ''t`'`���ys_..w�/J
construct the project(Sec.9060.Business and Profusions Code:)The Comustior's Li'
cave law docs not apply to an owner of property who Wilds or improve tWmon,and. j f /`�
who contracts for such projectvam
s with a eoncKm s)licensed pursuant the Conwmp
c /]
IT:,
License Law. '} r
❑i am rxcmpt under Sec. ,B&P C for this reason
Owner Dau
WORKERS COMPFNSATIONDECLARATION
1 hereby of itm under penalty of perjury ane of the following declamdov:
I haw and will maintain a Ccnifinm of Consent to se)(-imsure for WorlrcesCompcn-
anown,as provided for by Section 3700 of the LeWr Com.for the performance of de
work fo which this permit is ivied.
have and will maintain Worker's Compensation luurmce,u roquimd by Section
3000 of the laWr Code,far the performance of dm work for which this permit is issued.
My Worker' Co{ry,1e-s Oren Inscunna eerier and Policy number
�one
�1
Carver.a-�/a✓x-s-T�l kl'� Polity No.:�'�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not W completed lithe permit Is forone hundred dollars(SIW)
or loss.)
1 Unity Nm in the performance of the work for which this permit or issmd.I shall not '
employ any person in any manmrso u m become subject to the Workers Compemsahon
Laws of Calif 1.prim
Applicant
NOTICE TO APPLICANT:If,after making this Cenificale of Exemption,you should
become subject in the Worker'.Coomm iom provisions of the LOW,Code,you most
.,O forthwith comply with such provisions or this permit shall W nevo
deed reked.
'Euj CONSTRUCTION LENDING AGENCY
F I hereby affirm dot then iso construction lending agency fat the performance of
!Yth41,e work for which this permit is issued(Sec.30Cl,C.)
CLW A lcndees Name
.7 Z lcndch Addtus
V O 1.nee that I have read this application and sum Nu the show information to
Dw fir Cardin I agar m comply with all city and county ordinances of and sum laws relating m
pV allow,nmennswctionand farebyamhodmmprtsenudws of this city wcnmr upon de
yaWw, (W tionedpropene forivpeni an Ice,hi.
(We)agree w cave,indemnity and keep harmless w City o(Cupcngo agairm
h Iiacoisequence of rius
granting
tlof this Permit. may in any vnyamm gainst acid City (
V z inconsequence of the gaming of this permit. _
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Signature of ApplicanUConuactor Data Re-roofs -
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant ata.or handle huudous material
az delimit by Ne Cupertino Municipal Code,Charlie,9.13,and the Health and Safety
ode.Section 35532(x)?
Yu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or fuwm building occupant M expop so m ar devicca which If a roof is installed without first obtaining an inspection,I agree to remove
mit fix dom air conuminanu u fined by the Bay Area Air Quality Managcmcnt all new materials for inspection.
7dom
istrict?
❑Ycs Nu
I have mal the hue dous materials mquiremenu under Chapterh.95 of the Califor.
ce Health&SafctyCom.Sanies 25505.25533 and 35530.1 underaund thatifde Wilding
not currently hate a stnent that it u my miummil ility to utily the Otto ant ofthequ' me which...��e tpnorw�i arta a.Cmtifica f cu
/�� ,� k�LGrr�-Cltia� :Ila /y � Signature of Applicant Date
/
Daimler orauthmixedagent D,m All roof coverings to be Class "B"or better
Mlzo
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408) 777-3333
�UPEI�TINO
Building De artment
JOB ADHD' 9ESS: O n at I C-t PERMIT # O-S-03 Olys
OWNER'S NAME: ynro-n ya,7_d__n k5 PHONE # gow- asa 3
GENERAL CONTRACTOR d,4 (,J = �, FAX # I.ST- — Zq C1
kn i,o Gas
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 I ln�2� e� Inc, a 3i 1
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
1 .hnw.o.
Owner/Contractor Signature Date
CITY OF CUPERTINO
WATER NEATER o Ste' 3
eCUPERTINO PERMIT APPLICATION FORM
APN# 3 )-(o - 39 - S (� Date: �311d S
Building Address:
Owner's Name:. kQia �i Ph t�Og- aSoZ- I
WA
1fvl \/Qzao- 1 g
Contractor: Phone: License#:
lJAt � L. -7 6 -3 �
Contact: Phone: Cupertino Business License#:
CA ri's C;U a _ - a 1 311
Building Permit Info: /
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: a(-SMrc lust of t(3
f
Residential J Commercial ❑
Cost of Project: _
• Strapped ❑ On Platform ❑. Bonded ❑ _
New Location ElReplacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
J PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
7