05020037 CITY OFCUPERTINO /x�>'��ryn.;y.�p ;�( y�� y �/'�•s�7�,r�'�'a
BUILDING DIVISION PERMIT VL\sl'11211:I�1trlVlLLYlAffp1\
r.°pr<i'w6$'"a F^.v?i
BUILDING ADDRESS: HOT WATER INC PERMIT N%5020037
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO,
650 298-8494
ARCHITECDENGINEER: BUILDING PERMIT INFO
RLDO ELECT PLUMB MECH
p I�
atop LICENSEDMatImeOhenAdunderSDECLARATION JobDescri tion
+(j 1 hereby affirm Net 1 am licensed under proriaiona of Chapter 9(commencing s p
n� with Section]g1U)af DiMdan3of the Budrru sew ProfeWona Code,and my license is
hrdlmreeawercec 7� REPLACE WATER HEATER
License Clas. Lk..
Dat /�� "011'E r nom"
ARCHIIECI•S DEc'Li 70th
',� 1 undersand my phos MVI bu usetl u public records
Licensed Professional
OW NER-BUILDER DECLARATION
1 hereby sRrm Net 1 em exempt from the Contractile.License law for the
o G following reason.(Section 7031.3,Business and Professions Code:Any city at county
$ which requires a permit to enrotrwt dor.Improve,demmish,Or repair my summers
prior to its ISMANO.alta requires,the applicant for such permit as Nc a All clement
that he is licensed pursuant to the provisions of the Contractor's have Law(Chapter 9 Sq.Ft.Floor Area Valuation
(commencing with Section 70D0)of Division 3 of the Business and Professions Code)or
Nat In Is exempt therefrom and the bub fa the doted assumption.Any violation or
Section 703U by nary applicant for a permit subject,the applicant in a civil penally of
am mom Nan five hundred dollars(5300). 5 n�e10 O Occupancy Type
0 1,u owner of the property a mY employees with"Sun Neirsale ampewtlon,
will do the wash,and Ne=do.is mulmumded con0ered lmade(Sec.Russ,Businea
and Pmfewamt Cwt:The Comrecton License Law does mot apply to an Owner of Required Inspections .
property who bu Ilds or Improves Merton,ave who does such work himvlf m through his
own employees,P.Adcd that such Improvements art not ntended orafrened for We.if,
however.Ne building or Improvement is said within aro year of mmple tete,the owner.
Wilder M0 hast tie burden of proving that he did not build Or Improve for purpose of
ask.).
❑1,as owner of Use property am exclusively conuutinl with licensed antrutan in
construct tie project(Sec.7011.Business and Profesdow Code:)The Contrmots U.
ave Law dos not appy t an owner of property who builds or improves theran,and,
who contruu for such pmkcm with a comoudar(s)licensed pursuant t Use Conmctofs
License law.
❑lamexemptuwer Sec .Bk PCfmthisreawn
Owner Data
73700 WORKER'S COMPENSATION DECLARATION
I hemby IMM under penalty of perjury oar of de following Ueclaations:
I Nveand will maintain ACenllicate of Consent to se161nsum for Waftei Compen-
Uan,u provided fa by Section 37W of Ne Wor Code.fm Na performance of Ut
lk far whit this permit is based.
CMrr_hm`va and will maintain Workers Compensation Inwrena,u required by Section
of me Labor Cade,for the performance ofUro work for which this permit is lured.
yWorkda Compensation Inwnace prim tad Policy numberoder: &fzafi y=Mno( Policy No: 154A3�� .
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE _
CLbhsection need ant W compleletl If the permll Is forme hundr ldellan(11M)
or leu)
1 certify Not in the performance of the work for which this permit Is issued,l ahan not
employ any person in any manner sou an become subject to Me WoMers'Compenutlan
Laws of Califnroia.Data
Applicant
NOTICE TO APPLICANT:IL a0cr making this Continuum of Exemption,you should
become subject to Ne Worker's Compensadon prodslons of the Inter Cade,you muss
.JO forthwith comply with such pmvisiona or this permit Mall he cataract revoked.
r Di CONSMUCDON LENDING AGENCY
.�.. I hereby alllrm that Mere Ire a coromsexim lending agem y for the performance of
IY 0m work fm which this permit is ivad(Sec.3077,Co.C.)
WM Q Lender's Name
O z landed Add.
U O I certify that I have mad this application and sat that this above infmnmim h -
L6^" COMM I agree to comply with dl city and county ordinances and mule laws relating to
blow construction,adion,awherebyauthorisetpmaentstiwt of this city menmr upon the /
W ahove•mentianw propenY fa ivpcetian purposes L
p3, cm agree ro naw,indemnify and kap may
In m w City of Cupenina againat /'a'�
(A IIab1IMM.judgmenta,eau and erepensee which mryhuyvny accrue gtlnnaid City
J 7 in consequence of the granting of this permil.
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU C REGULATION$. i` �y/Or
;Ow
-3 Re-roofs
Signature of AppncantrConeremor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tie applicant or future building mcupantse a at handle haasldous material
u dented by tie Cupertino Municipal Code.Chapter 9.12,ave the Health and Safety
,aiiaLewe,station 15532(a)?
2,44 All roofs shall be inspected prior to any roofing material being installed.
❑Yu
Will Me applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Fail hauldate air cmtsmlvnu as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes 2fr
I have mad the huan/oes materials requiements under Chapter 6.93 of the Califor•
nia We?"SmctyCwc,Sections 25505,x3533 and 23331,I understand that ifUc Wilding
does tel.una.Lly have•tensnt.on It is my responsibility b notify Ne aceupmt of Ne
myuimments which mus �I p�riayw lvuena of a CcNOcam ofpccnpamcy. Signature of Applicant Date
m e4 -` - `'°i ' '2 Yz� All roof coverings to be Class"B"or better
Own"or mthorised agent Data
Community Development
9 10300 Torre Avenue
Cupertino CA 95014
I Telephone(408)777-3228
CI Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS: PERMIT#
�y77 jfZn16r� P/0ce✓ OS o2-aO 37
OWNER'S NAME: -W2vi a tt PHONE # y08-�5Z - 9690
GENERAL CONTRACTOR: //z7t I1/a er /nom FAX # 650 -&31-1yy�
I am not using any subcontractors:
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 /fat vVafei-- A c o2 f Z//
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
r.
{
CITY OF CUPERTINO 7WATER HEATER ��'�� ° �2
CUPERTINO PERMIT APPLICATION FORM
APN# 3 `59 - 3 - O 3 Date: /os
Building Address: ��+
11-17-7 4a 5 n l�r-d 01a C 2
Owner's Name: Phone#:
- W e Y08- asz - 9& 90
Contractor: Phone: ,License#:
4Dt' fer /n C-. /0 36912-
Contact: Phone: Cupertino Business License#:
C—,` rrS u,S-la nr
Building Permit Info:
Bldg ❑ Elect ❑ Plumb 19-� Mech ❑
Job Description: n"
uJ�-fer' �afee- ��/Smrc PeSfi'anI5 TtP
Residential Commercial ❑ fo EK�erior-
Cost of Project:
Strapped L1 On Platform LJ Bonded
New Location ❑ Replacement
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
t