04010056 (2) CITY OF CUFERTINp .'�'n' r"
5 BUILDING DIVISION PERMIT r-CONTRACTORjINFORMATION
BU ILDINGADDRESS: HOT WATER INC PERMIT NO04010056
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
(650) 298-8494
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
sena LICENSED CONTRACTOR'S DECLARATION -
1u'FF I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
SZty with Section)(MAB rDivision3ofthe Businessand Pmfcssionx Code dmyliccnu is
j� in mu force and erre`L WATER HEATER REPLACEMENT
? License Class Lk.s
�F� Dale Can A HITECT$DECLPft TI ds ��f}n rs
-'It nstanJ y plans shall he used as puhlic records u1///fin 'rY1
J y U rrV Ms,raw
Zar Licensed Professional 'f
0 OWNER-BUILDER DECLARATION AUG 19 2004
S 1 hereby alarm the I ore exempt(rum the Conlmctori License Law for the
00 following mason.(Secdun 7031.5,Business and Profeesiaa Code:Any city or county
K m which requires a Pront to construct,alter,improve,demolish,or repair any structure
Prior to its issuance.alsoo:yuir.me applicant for such permit to file a signed statement up,�
Nal he is licensed pursuant to the provisions of the Contractor's Limns taw(Chapter9 Sq. Ft. ao r.�� Valuation
yF� (commencing with Section TODD)of Division 7 of the Business and Profusions Ccat or ,�tl�v
a. doer he is exempt tMmfrom add the basis for the alleged Gumption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 5WN_1'I11*@rO 0 Occupancy Type
not more Nan five hundred dollen($500).
❑1.as owner of the property,or my employees with wages as their talc compensation.
will do the..,it.and the ewctum is not intended or offered for sale(Sce.9Bad,Business
and Professions Cade:The ContnmLicenses License Law does not apply m an owner of Required Inspections
property who builds or improves thereon,and who does such workhimulforthtough his
own employees,provided that such improvements are,not intended mortared!for sale.It.
however,the building or improvement is sold within one year of i nmpletion,Ne owner.
builder will have the burden of proving that he did not build or improve for puryou of
ale.).
❑1,as owner of Ne property,am exclusively connecting with licensed contmnars to
conswet the project(Sec.9044,Business and Professions Code:)The Contractor's Li.
crime Law does not apply tom owner of property who builds or improve themon,and
who contracts for such projects with a eomsaetoo(s)licensed pursuanun the Contsi ._
License law.
❑1 sonexempt under Sec. .B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby aRren under penally,of perjury one of the following dxlaatimm:
1 have and will maintain a Certificate or Consent to self-insure for Workers Compos
cation,as provided for by Section 3900 of the Labor Coat,far the performance or the
work for which this permit is issued.
ave and will maintain Worker's Compensation Insurance,as required by Section
of Nc labor Code.for Ne performance or the work for which this permit is issued.
My Worker CfyB a anon launntt cortin and Policy num�ba, amort:(]
Cartier: I zA PolicYN,.: CSy�i3��
CER I IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu sesuma need nor ac mmplried if the permit is rens hundma dollarsolfq)
nr less.)
I certify that in the performance of the work for which this permit is issued.I shall at -
employ any person in any mmner u a to become subject o the Workers Compeaation
Laws or Califomia.Data ,
Applicant _
NOTICE TO APPLICANT:If,after making this Coni ficate of Exemption,you should
become subject to the worker's Compensation provisions of the Latae Code,you must
Z forthwith comply with such previsions or this permit shall he deemed revoked,
ZO CONSTRUCTION LENDING AGENCY
[— I hertM1yeRdm that there is a construction lending agency for the perrormance of
athe work far which this pertna is issued(Sec.307,Civ.C.)
D] tender's Name
y
Uz Lender's Address
D,O I ttnee that 1 haus mad this application and sine ccs the above information is
C H Wilding agree to comply with yatll ity and county
epresnNinamesand cute laws enter upon the Q U buildingconrvied ra cr hereby ectionisrepresenutivcs of Nis city to corer upon the
ahavo-mcmm gree tocrtyforimpeni an arreskeep es.
(~ y
(We)agree to nus,indemmfyandkeep hamorkial inmtheyare or Cupcnit against
N inscaitiu sine ofthecoming rixpcnusmit. may in mywayaccmc against mid City IIF
V z APPL CANTeUNDERSTANDSting of this ANDSWILL COMPLY WITH ALL NON-POINT Issued by: Date ` w
SOUR=IONS.
Z a f Re roofs
Signature o Applican manor / be
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle herudous material
as defined by the COpenim Municipal Code.Chapter 9.12,and the Health and Safety
0 Yu
code. ea zsvz(a)± All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or Towne building Occupanttau equipmentor devices which If a roof is installed without first obtaining an inspection,I agree to remove
it huvandous air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
strict?
dYcs Aivo
Ih.Sgct theh.aeDo 25R)alsequirtmemts4.l un hawdffi5ofthe Wildinr.
nix Health&Safety Cede.Sccdoa 25HI5.25573 and 25534.1 unJcrsland this if the building
does not currently have a anon,that it is my mspunsmility m nodfy the arcupml of the
mgeirtmmuwhreh albcMet poor wissuance nracenifickar man Signature of Applicant Date
Owner or a�th ''rcJ 7,m, All All roof coverings to be Class "B" or better
CITY OF CUPERTINO
sum WATER HEATER �_s
CUPERTINO PERMIT APPLICATION FORM
APN 113_(-6
3_(-6 L s- o`cp— Date:
Building Address:
Owner's Name: Phone#:
Contractor: Phone: License#:
/ 6-&S)
Contac Pyone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb�O Mech ❑
Job Description: W
, Ij-1 alb /
Residential J2, Commercial ❑
Cost of Project:A '..
Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Re lacementeta
Qty.
A li if b " Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMTI'FEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING