04030186 CITY OF ZTPERTINOBUILDING DIV PERMIT1 ' T!��'� ' '�'TI "^''
BUILDING ADDRESS: PERMIT N0.
HOT WATER INC 04030186
OWNER'S NAME: PERMIT ISSUE DATE
CINDY WANG OR A RJ A NP A 17R
ONE:
SANITARY @ftOL NO.
I
CHITECDENGINEER: I BUILDING PERMIT INFO
BLDGELECTO PLO MECH
O
on LICENSED CONTRACTOR'S DECLARATION l Job Description
1 emeby affirm fee,]em licensed under provisions of Chapter 9(commencing
d.ffeull(omeandcRetto REPLACE WATER HEATER5 ... Lic.Nse— m Contractor
ARCH IEC LARA ION p'
? U I understand my plana shall be used u public records
AUG 2J 2004
6
uo Licensed Pmfcaai...I
OWNER-BUILDER DECLARATION
1 hereby affirm the,1 am exempt from dm Comrsctors License Law for the BUILDING
u
O d following o on.(Section 703 1.5,Business and Professions Cade:Any city at county �J tl�ti
Mwhich m9uircs It Permit In...mro.I.eller,improve,demolish.Or¢Pair my structure
rZr pd.,In its issuance.also requires the.pplownt for such permit 1.file astgnodstamment
XEM that Jus is licensed pursuant to the previsions of the Common's Limman Low(Chapter 9 Sq.Ft.Floor Area Valuatio
we 1•$ (commencing with Section 7W)of Division 3 of the Business and Professions Code)or
�.. that he is exemptem
therefrom and the basis for the alleged exemption.Any vinladon of
Sidon 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 Q�;`I' I eI�0 Occupancy Type
not marc Wan the hundred dollars($=.
❑I,uownuofthepmpeny,ormyemploycuwithwegesuthehmlemmpenmtion, '
will do the work and Ne swctum is not intended oroffmad(oracle(Sec.70th,Business
and Prolamin.Code:The Contractor's Licemm Law docs not apply In an owner of Required Inspections
propenywho Wilds orimproves thereon,and who doe.suchworkhimselfor,through his
awn employcea,provided thatamh improvements arc mtintended oroffered for sale.if,
however,the building Or improvement is sold within on yeti of completion,the owner.
builder will have the burden of proving that he did not Wild or impmus for purpose of
tile.).
❑1,as owner of the prepeny,am exclusively contracting with licensed contractors to
construct the project(Sec.70".Business and Professions Code:)The Contractor's Lt.
came law does not apply m an owner of progeny who Wilda or impocom Ibe¢on,and
who contracts for such projects with acomzmmKs)licensedperwontro the Comment's
License Law.
❑1 am exempt under Sec. .B At PC for 13 moon
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations: -
1 have and will maintain aCerdfieam of Consent to self-insure fm Worker'sCompen-
on,as provided for by Section 37W of the labor Cade.for the performance of the
7cru3OO
rk for which this permit is issued.
haw:and will maintain Workers Compensation Insurance,as required by Section
dof the labor Cade,for the performance of the work for which this permit is issued.
y Worker's Compensation Insurance carrier and Policy number arc:
me S i/-}Tr' 1 g Pollry No.: I S Lt in P G
RTIFICATE OF EXEMPTION FROM W ORKERS'
COMPENSATION INSURANCE
(Thu auction need notbeeompleted if the permit is forano hundred dollars($100)
Or less.)
1 mildly that in the performance of the work for which this permit In issued,1 shall not
employ anyperson in any mannerso as In become subject o dm Workers'Compensation
taw.of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m the Worker's Compensation previsions of the labor Code,you must
.`O forthwith comply with such provisions or this perrell shall be dccmad smoked.
'Z y CONSTRUCTION LENDING AGENCY
[—i I herchy aRrm that Nem is a construction lending agency for Ne parfmmanec of
f� the work for which this permit is issued(Sec.3097.Civ.C.)
W A Lenders Namc
z Lenders Add..
U0 I cenify that I have read this application and Bme that the be.information is
f-' corbs L 1 agree to comply with all city and county ordinances and sum laws relating to
DU Wilding construction,and hereby authorise rcpruenutives of this city m enter upon the
6Wi ahovmmemioned property for inspection purposes.
(We)agree m save,indemnify and keep harmless dm City of Cupertino against 42 9
„Fy V2 liabilities,judgments.costs and expenses which may in my way accrue against mid City
Uin consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N N-POINT Issued by: Date
SOURCE REGy1,AT S.
�1/ X12 .P �.1� z�/�W Re-roofs
Signature of ApplicmVCombecmr Dws
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applium ar future building occupant smrc or handl.hazardous material
as de0ned by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
,IRL(Codc.
p $❑len 25532(a)?
Ye. MN. All roofs shall be inspected prior to any roofing material being installed.
/ Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes [I NO
I have mad the hazardous materials requirements underCWpeer 6,95 of the Califor-
niaHcallh&S.fesyCode,Sections 25505,35533 and 25534.1undemand that if tiro Wilding
dose not Concelly ham a mnana Nal it u my responsibilitym nosily the occupant of thc
myviremcnts which Wmel pnonuissuancc oh Cenificam of Oce ar Signature of Applicant. Date
dagent DEW All roof coverings to be Class"B"or better
Owner or authorizud agent D�—
Community Development
10300 Torre Avenue
6 r Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Buildin Department
JOB ADDRESS:1 y3 /2l//t�oS� PERMIT o3 dl e(2
OWNER'S NAME: Z>4 C l-S r(�S�9N / PHONE 6
GENERAL CONTRACTOR: FAX # KQ -6166
I am not using any subcontractors: Q3 Z�
Signature Date,
Please check applicable subcontractors and complete the following information:
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, �� C �
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Contractor Signature Date
CITY OF CUPERTINO
WATER NEATER oq `'3
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
3 - 17 -���I tgl�� t
Building Address
3'1 Qrrm(
Owner's Name: Phone#:
�1 W 7;JG -
Contractor: HOT WAT , INC. Phone: -r �I License#:
963 INDUSTRIAL ROAD UNIT D w 0 T / t ((3 .3 62 Z
Contact: Phone: Cupertino Business License#:
�t 31 I
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ul/ Mech ❑
Job Descript ion: , , \o&er
Residential Ey Commercial ❑ ` V
Cost of Project:
�. Strapped On Platform Bonded
New Location ElReplacement
/
Qty. if .
A licable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY EnergyBUILDING
BUSLIC Business License BUILDING