05020037 (2)DIVISION PERMIT
nUILUlnu AuUKu4: T I HOT WATER INC I YC11M1 t N`bS 020037
nn nn nmmsvnnn.. ..
full
NAME:
1 hereby affirm Net 1 are licensed under provision, of Chapter 9
0
1 undersand my plans Mall be used u public meorN
OWNER -BUILDER DECLARATION
1 hereby alErce Net 1 em exempt from the Conuenoh Liame law for the
following reason. (Secuun 703 1.3, Buslneu and Professions Code: Any city at county
which acquires a permit to eomtruct, titer, bnpmw, demolish, m repair my southern
prim to its I6um6a. also mquims the applicant for such permit to 01c a signed wmmeal
that he is licensed pursuant to the provisions of the Connector's Matta taw (Chapter 9
(commencing with Section 7000) of Division 3 of tho Bud max, ad Pretensions Code) or
Man he is exempt thereRore and the bub for the tlteged esernptioo. Any violation of
Section 703U by my applicant for • permit subjects the applicant in a civil penalty of
net mom than Rn hundred dollars (5300).
D L u owner of the property army employees with "Sun Nelrsole compensation,
property who bu ild4 a Improves Mercer, and who does such worn hi m sel f or through his
own employees, P.Adcd that such Improvements an, not intended or offered for We. if,
however. Ne building or Impmwmenl is said within aro year of completion. the owner.
Wilder will haw tie burden of proving that he did not build in Improve for purpose of
❑ 1, as owner of the property. am exclusively conuxetinS with licensed examines re
construct the project (Sec. 7044. Business and Profeadons Code:) The Comu a mr's U -
cense law don not Appy m an owner of property who Wilds or Improves thereon, and
who conuuu for such projects, with a eommme(q licensed pursuant to de Contractor's
License law.
❑ IameaemPtundin Sec .Bk PCfathlsroaann
Owner Data
WORKER'S COMPENSATION DECLARATION
I hemby IMM under pecoly of perjury am of the following declare buts:
1 haw and will maintain aCenlncate of Consent to sel6lmum farWorker's Compen-
sets., as provided for by Section 37W of the Labor Code. for the performance of do
and will msian ie Worker's Compensation Insurance, u required by Section
e lata Code, for the performance of ds, work for which this permit Is Imad.
es Compensation Insurance artier and Policy number ser: pp qq
-/ (l. L YM KO( Policy No.: /6 SIO JO
not hecomplesed lithe permit Is formm headmddollm ($I W)
certify Not in the performance of the work for which this Permit Is Issued, l shin not
replay any pemon in any summer an as an become subject to the Woolen' ComPensatian
Awa of Ctllforela. Data
NOTICE TO APPLICANT: IL after making this Cenincom of Exemption, you should
become subject to Ne Worker's Caropemadon provislom of the IaMr Cade, you must
.J O forthwith amply with such previsions ser this permit Mall he lamed levnkcd.
r Di CONSTRUCTION LENDING AGENCY
[..t .�.. 1 hereby a1Rrm that them Is a comuuclion lending agency for Be, Performance of
C the work for which this permit is issued (Ser. 3077, Co, C.)
PERM ISSUE DATE
Job Description
REPLACE WATER HEATER
IIIQ Leader's Name
cl,O z Landers Add.
U O 1 certify that 1 hm mad this application and sum that the aWve informmlon 4 -
I, ^" cortm I agree ......Ply with 411 city and county ordinances and state laws relating to
O`rJ^ building construction, and hereby authodmmpmmmmdwsorthis city mAmerupon ft
t>a shove -men kmad progeny fa Impaction Purports
p3, (We) agree ter an. indemnify and keep hornless the City of Cupertino against
res Ilabllides.judgments, cote and expenses which may in any way accrue against aid City
U 7 in conaegance of the granting of this permil
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by:
SOU C RECULA770N$. i` �y/Or
�� .3 Re -roofs
Signstum of AppllcantlComencer Dam
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Oyu r
pt%
Will Ne applicant or future Wilding occupant use equipment or devices which
it hammum air eammimna as defined by the Bay Area Air Quality Management
District?
❑Yes 21�r
I have mad the hatndm,smamrials requirements under Chapmr6.93 of the Califor.
nim We?" SafdyCode. Sectom 25303.33333 and 25334, I understand thmifdc Wilding
does not currently Mw • laant. Rut It is my responsibility to ratify the occupant of the
requlmmcma which most Ac gel prior In issuance of a CcNOcase off5ccupancy.
Ft.
Required Inspections
omwtrvu
Date 2 a !-)
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better
1
� 19
CI
UPEkTINO
4
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
JOB ADDRESS:
-�y77 jfzn/,�rdL P/0 c-,7—
PERMIT #
OS ozoo 37
OWNER'S NAME: -W2vi a rl
PHONE # y08 X52 - 9690
GENERAL CONTRACTOR: //fit I1/a er /nom
FAX # 650
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
Owner/ Contractor Signature
112
—y a�
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
/fat W ale -- A e-
o2 f Z //
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/ Contractor Signature
112
—y a�
Date
r.
r
ciao
CUPERTINO
CITY OF CUPERTINO
WATER HEATER ��'�� ° �2
PERMIT APPLICATION FORM
APN # 3`59 — 3 — O 3
I
Date: /os
Building Address:
11-17-7 54an/�>rd (ala U2
PPERMITFEE
Owner's Name:
Phone #:
- W e
Y08- asz - 9& iv
Contractor: Phone:
#:
4Dt' fer /n C-. -(n a /— b Y 9 V
,License
Z* 36912--
Conta�ct:Phone:
Cupertino Business License #:
C—,` rrS u,S-la nr
Building Permit Info:
Bldg ❑ Elect ❑ Plumb 19-�
Mech ❑
Job Description: �"
uJ�f�r �� a-feSe/5/rirc r�S{ravr/5 TtP
Residential Commercial ❑
fo EXer tor—
Cost of Project:
Strapped El On Platform 11 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