05020117 (2) CITY OF CUPERTINo
BUILDING DIVISION PERMIT VCONTRACTnRaINFORMtATIQN ;�.
BUILDING ADDRESS: WATER HEATERS ONLY PERMIT NGO 5020117
10059 OAKLEAP PI.
OWNER'S NAME: PERMIT ISSUE DATE
JNAN NAYAK 970 E. MAIN ST SUITE 200 02Z16/2005
ONE: SANITARY NO. CONTROL NO.
(800) 835-5946
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 � 0 (�
joo LICENSED CON'TRACTOR'S DECLARATION
to I hereby affirm,hal 1 am licensed under provision,of Chapter 9(commencing lob Description
with Section Division S of NC Business and Nofessions Code.and my license is
n in full force anJ erre L U d"
fE Licen 1 �3 a_ 7573 REPLACE WATER HEATER Mq
p Dau V Contractor
ARCHITECTS DECLAR TION
aU I understand my plans shall Nosed a public records ///��p \ ,
e G Licensed Professional ,^`// n�� v ?045
cog OWNER-BUILDER DECLARATION !�U
<I I hereby affirm that 1 am exempt room Ne Contractors License Law for the
p o following reason.(Section 7011.5.Business and Professirm Code:Any city or county ff
which requires a Permit to construct.alter,improve,demolish,or repair any stmcwm Oh'" r�1 16 0 0
-Z j, prions its issuance,also requires the applicant for such permit to File a signed statement
go he is licensed Puuu,n,to IW pmvismas of tnc Coo=t.f's License Loa(Chapter 9 Sq.Ft. Floor Area V Valuation
u (commencing with Section 78(0)ol Division 3 of the B usiness and Professions Code)u,
_ that he is exempt Ihcrtfmm and de basis for Ne alleged exemption.Any violation of
Section 7831.5 by any applicant for a permit subjects He applicant o a civil penalty of
not mm than five hundred dollarsi :3 2&NEt�arO 0 Occupancy Type
D I,as owner of the property,or my employees with wages as their sole compensation,
will do Newark,and use sweaure is not intended or offered for sale(Sec.7844.Business
and Professions Code:The Contrarlm.uanu Law does not apply to an owner of Required Inspections
propcny who builds or im sows thermn,and who doessuchwork himselfmInmugh his
own employees,provided that such impmwmenu are not intended or offered formic.If,
how wr.the building or improvement;,sold within one year ofcompletion.thcowner-
builder will have the burden of proving that he did not Wild or improw for purpose of
sale.).
D 1,as owner of the property,am exclusively conning with licensed contractors to
convect the project(Sec.7804,Business and Professions Code:)The Contractor's Li-
ccnse law docs not apply to an owner of property who Wilds or improves demon,and
who cones for such projects with a contractor(s)licensed pursuant o flue Contractors
License Law.
D l am aempt undo,Sec. ,B&PC for Nrsnason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ane of the following doclarn;otu:
40 1 have and will maintain a Certificate of Consent to self-insum for WmtehCompen-
satioo,as provided far by Section 3780 of de,Labor Cade.for the Not....of the
..wLI�ork for which this permit is issued.
1y}I have and will maintain Workers Compensation Insurance,as required by Section
37W of the labor Code,for the pe,formantt of the work for which this permit is issued.
My Wr,kc,'s Cn-gjc don In[s...canicran
d Policy number aa: 11
Cartier: J'4 a O(.._ Polity
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This seed.need not Wcompleted Hthe permil is foronc hundred dollars($KK)
or lcsa)
I certify that in Ne performance of the work for which this Permit u issued.I shall nor
employ any pcnmn in any manner an as w becomc Subject to the Workers'Compensation
Laws of Celifmnia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become mbjecl to the Workcr,Compensation provisions of the,Ismv Call.you must
=O forthwith comply with such provisions or this Permit shall W deemed revoked.
Z h CONSTRUCTION LENDING AGENCY
1 hereby af8,m that Nen,is a eonstrvclum lending-gamy far the performance of
X the work fur which Nu .it is issued(Sec.3097,Ci,C.)
1 0 IcnJcr' Name
7 z
I Lenders Addmu
J 0 certify 0211 haw read this application and,esu that the aWw infomutidm is
y corms.)agree to comply with all city and county ordinances and sou laws relating m /
CF.7 bu;ldinMconstruction,mN,ty hereby archon purposes.resenu,ivcs of Nu city mcnter Minn the
aM1ow (Weianed gree to any findmnify ankeeph
6th (We)agree,o costs indemnify and tech harmless the City u Cupertino against
Zl,i li,hKscajudgmcnh,g1roondof this confit. may in anyway acctuc against said City J1
J z A APPLICANT
of DERSTA gof,hia permit. � A
SOURCER UNDERSTANDS AND WILL COMPLY WITH
7�ALL��NON-POINT Issued by: Dale L
"� � 4A 5 Re-roofs
Signature O(Appicant/Confina,ter Data
HAZARDOUS MATERIALS DISCLOSUREType of Roof
Will the applicant lir future building Occupant store or handle havuduus material
as deaned by the Cupertino Municipal Code,Chapter 9,12.and the Hcallh and Safety
Ititonctreft,
le,Section 35532D)?
DYea QNi All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant o,future building Occupant use equipment If a roof is installed without first obtaining an inspection,I agree to remove
pct e v a nand rt Marta a men g
itict? us cies contaminants a aefincJ by me Bay Are,Ai,Qpolny Management all new materials for inspection.
District?
CYes `EM— ,
1 have mad the haa,dous materials requirements under Chapter 6.95 of the Califon
his Health&Safety Code,Sectiuu 35515.35533 and 8534.1 umcrsuM that if use Wilding '
s not curemly ham a unana Na,it u my respersi hili,y to noti ly the occupant of Ne
which mute nor.as cc rfa Cnoll.le fOccu cy.
�6 ✓� Signature of Applicant Date .
Owncr lir authorind agc D„p All roof coverings to be Class "B”or better
a, Community Development
1 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS:/00s'? Oak *0(0� PERMIT #a.50 Z d
OWNER'S NAME: /K awv h PHONE # 9 9 6 -S-7
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: 10a;& 99all., 0,t.L T
Signature T Date
Please check applicable subcontractors and complete the followm 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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile A
2Z/6 os
Owner/Contractor Sign tore Date
CITY OF CUPERTINO
WATER HEATER �5�� a ° 17
CUPEI�TINO PERMIT APPLICATION FORM
APN# Z / /,911
v J -3 Q Date: 2—/1 /O 5
Building Address: /00.5-9
Owner's Name: �/� n Phone#:
79 6 _ 7 y 7
Contractor: �a � � � Phone: License#:
dad 835 s9 (16 345 '13
Contact: Phone: SCupertino Businessicense#:
�
Building Permit Info: i8P
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: �L JS --P
Residential/Y� Commercial ❑
Cost of Project: 16 0o OZ
Strapped ❑ On Platform Bonded ❑
New Location ❑ Re lacement
Qty. if
Applicable Fee ID Fee Description Fee Gr
ou
BPWHEATER Water Heater/Vent BUILDING
/ PPERMITFEE Plumbin Permit Issuance PLUMBING
/ BENERGY Ener BUILDING
BUSLIC Business License BUILDING
2�6 2-7