04100127CITY Oi CUPF.R'fINO
BUILDING DIVISION PERMIT
CONTRAC1nR INF®RMATIONS <;
BUILDING ADDRESS:
PLUMBING
PERMIT NI0410 0127
21725 TERRACE DR
OWNER'S NAME:
PERMIT ISSUE DATE
BILL MCCARTY
170 BRANNON DR
10/19/2004
]ONE:
SANITARY NO. CONTROL NO.
(510)376-4816
ARCHITECrIENGINLER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
I hereby Chapter 9
Job Description
p
affirm That I am limned uW visions of (commencing
with onion ](I(Np of sion3of the Busi and Profcminm CnJe.and myliccnsc is
mm �ceanQtI�pffet.
Lic Onl t s Lic. .g.a� �4 �
REPLACE WATER HEATER
- F I NAL
it -
Data Cummer Y
r
ARCH DECLARATION
E
1 understand my plans shall he used as Public months
l be use
'
(ICT 2ID 1004
Licensed Professional
OWNER-BUILDER RDECe
I hemby affirm thus CmicaON
csempl from the Colons Co License Law for the
massa. (Section ]1151.5, Business and nm Calc: Any city or musty
1.
which ve. de or repair any
permit to construct, alter, improve,
whichrequiresits
$750
h Permit t
prim m its issuance, also rcyuirhe the applicant for such Permit Llice natured mammem
u n alumni
thathelicensedit pursuant o the Provisions of the Co law (ChaptersCode)9
nd
Sq. Ft. Floor Area n
(carouses avewish Section 7 Easiness Pioc Code) or
of Divisions ofthe Business ancon,
Any
Net he is exempt therefrom and Ne Emu for the alleged eacmption. Any violation of
and
Section ]031.5 by any eppcicant for a permit subjects Ne applicant a civil penalty of
e
Occupancy Type
not more than rive hundred dollars(5500).
❑ 1, as owner of the property, m my employees with wages as their sale compensation,
will do the work, and fie structure is not intended or offered for sale (Sec. 7W, Business
and Professions Code: The Contractor's License Lew does and apply to an owner of
Required Inspections
property who builds or improves thmems. and who does such work himself or through his
own employees, provided that such impromments arc nal intended conferred forade. If.
however, the building or improvement is anld within one year of completion, the owner
builder will have the burden of Limiting Nn be did not Wild or improve for purpose of
saky.
❑ 1. as owner of the prod em exclusively contracting with licensed attractions Is
construct the project (Sec. 7044, Business and Professions Cabey The Corracdori Li.
cense Law dues not apply to an owner of properly who Wilds or improves Hereon, and
who contracts for such projects with a con0anous) licensed pursuant o the Contractor's
License Law.
O 1 am exempt under Sac. B & P C for moron
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of life following declarations:
I hem and will maintain a Certificate of Consent to self-insum for Worker's Compen-
sation, m provided for by Section 3700 of the Labor Code, for Ne performance of the
work for which his pemtil is issued.
❑ 1 have and will maintain Worker's Compensation insurance, as required by Section
3700 of rhe Libor COde. for the performance ofthe work for which this Permit is issued.
MyW(orkcrs Compensation Insurance carrier and Policyher art: '--f�
Cartici: fs.10 _ imp(' Policy Na: I
Rtil
EXEMPTION ANTE OF EXEMPTION FROM WORKERS'
l
/L—�CERTI�
COMRENSATION INSURANCE
mus suction need not Ec completed if the permit is format hundred dollars (Slfkl)
to It
I certify that in the performance of Ne work for which this Permit is issued. 1 shall not
employ any person in any manner an a to become subject to Lou Worken'' Compensation
Laws of California. Did
Applicant
NOTICE TO APPLICANT. IL after making this Cenifem, of Exemption, you should
become subject to the worker's Compensation provisions M the Labor Code. you must
forthwith comply with such provisions or this Permit shall ho deemed invoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency Int the performance of
the work for which this permit is issued (Sec. 3097, Co. C.)
Lender's Name
Lender's Address
1 certify Net I have read this application ant nate Nal the show foundation is
cored. I agree to cum Ply with all city and county oNinances and sme, laws rearing to
building construction, and hereby amrhorim representatives of Nis city to enter upon the
above-mentioned properly for inspection purposes.
(We) agree in save, indemnify and keep harmless the City of Cupertino against
Liab0ities, judgments, emu and expenses which may in any way aeemc against said city
in comequcnce of the gram)ng of this Permit.
/
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date 1
SOU RC EDULATI
Re-roofs
_
Type of Roof
/
_ 1.n.CL� to-K/-0L
gig re of Applic Damn Dam
HAZARDO
Will the dingMCLSDISCLOSURE
or furore building occupant stem or handle hvudous material
de0by the
a Cupertino
nn Municipal Code. Chapter 9.13, and the Health and Safety
C 32(1)?
Code,ElySection 35553(a)? es
All roofs shall be inspected prior to any rooting material being installed.
If roof is installed without first obtaining an inspection, I agree to
Will the appcianl or future building occupant use cquipol or devices which
remove
mit hav2rdnus air contaminants as defined by the Bay Area Air Quality Management
all new materials for Inspection.
Diol
Yes
I have read the hov duus materials requirements under ChaPmr 6.95 of NC Califon
nig licahh & Safciy Clvle. Secure, 255()5, 35533 and 25534.1 undersand mat if thc building
urea not cutently hum a mnom that it is my responsibility it, notify t uecupant of the
requiremeaawhathmust nema M1rlttissmace of. Cao,mupancg
Signature of Applicant Date
�- 4 Dll
g All roof coverings to be Class "B" or better
�"-
Owner or atomized Dam
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the fnllnw;no ;,,f�,.,,�,; ,r•
10-Iq-
Date
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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
10-Iq-
Date
•
9
ac
CUPERTINO
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
0,40(27
APN # 5 1 , - O 12
Date: 1 0 _ SCI — 0
Building Address:
--�-t;Q(2 A Ce�
PPERMTTFEE
Owner's Name: t 1� MGA k
Phone #:
4DS - a53 -AIDS
Contractor:Phone:
AI\ �A11 171 Urn 101
License #:
7C(1A Sqt C5
Contact: V- ylv% Phone:
�V�\1�1 S Aid 511)' lvto ] Go�i5
Cupertino Business License #:
Z3 C> 1
Building Permit Info:
Bld Elect ❑ Plumb
Mech ❑
Job ascription: l
`_
Residential ❑ Commercial ❑
Cost of Proje t to,,
Strapped El On Platform El Bonded El
New Location ❑ Replacement ❑
ty. if
nlicable Fee ID
Fee Description
Fee Groun
BPWHEATER
Water Heater / Vent
BUILDING
PPERMTTFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING