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09020032 POWNER!SNAME. OF CUPERTINO PERMIT DING DIVISION rE1�MI1 pERM1TNO. ____7 ADDRESS: 03 LILA AFFORD PERhIIrLSSUEDATE 'LrTTT 1�aTDTTTT T TTTTI *�Tny�T -- S CONTROL N0. INE: (6 61) 2 5 9 -7131 BUILDING PERMIT INFO PARCHrrEC-T/ENG1N1,E,FR:iNEER: BLDG ELECT PLUMB MECH CCLICENSED CONTRACTOR'S DECLARATIONIOb DeSCnptrOn firm that 1 am licetsed under provisions oC Chapter 9(commencing Z )of Division 3 of the Business and Professions Coode.and my license isWATER HEATER REPLCMNT . a. t 7-7 3(o p sulz se Class t-p CnContractor ARCHITECTSDECL RA ON e.2,-. A 1 understand my plans shall be used as public records 6 � 4 o y Licensed Professional OWNER-BUILDER DECLARATION o 3 1 hereby affirm that I am exempt from the Contractor's License Law for the c coo following mason.(Section 703 1.5,Business and Professions Code:Any city or county $Pi which requires a permit to conswct slur,improve.demolish,or repair any structure Valuation n- '^ prior to its issuance,also requires the applicant for such permit to file a signed statement S Ft.Floor Area z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q 2=0 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or y that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number not more than five hundred dollars($5om. 3590302-c . 0 0 p 1,as owner of the property,or my employees with wages as their sole compensation, Required Inspections will do the work,and the structure is not intended or offered for sate(Sec.7044,Business and Professions Code:The Contractor's License Law docs not apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale.If, however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sate.). C3 i•as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044.Business and Professions ilds deor improves thereon,Li- cense Law does not apply to an owner of property who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. ,B&P C for this reason 0[am exempt under Sec Dau_F Owner WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: have and will maintain a Certificate of Consent to self-insure for Worker's Compen- I as provided for by Section 3700 of the Labor Code,for the performance of the r which this permit is issued. ve and will maintain Worker's Compensation Insurance,as required by Section the Labor Code,for the performance of the work for which this permit is issued. rker's Compensation insurance carrier and Policy nnuu��`�O- 7Z4L^ �- Policy No.: CHR77FiCATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (this section reed not be completed if the permit is for rine hundred dollars($100) .) y that in the performance of the work for which this permit is issued,I shall not y any person in any manner so as to become subject to the Workers'Comperhsation of California.Date ant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must ,J Z forthwith comply with such provisions or this permit shall be deemed revoked. Z CONSTRUCTION LENDING AGENCY HhNr I hereby affirm that there is a construction lending agency for the performance of ✓ the work for which this permit is issued(Sec.3097,Civ.C.) W 0 Lender's Name Ow Lender's Address [certify that 1 have read this application and state that the above information is LUL C) correct I agree to comply with all city and county ordinances and state laws relating to Q U building construction,and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes W W (We)agree to save,indemnify and keep harmless the City of Cupertino against E" liabilities,judgments,toss and expenses which may in any wa accrue against said City Date U Z in consequence of the granting of this permit. ••y APPLICANT UNDERSTANDS AND WIL PLY WITH ALL NON-POINT IrRe-roofs d bpi: SOURCE TIO // — 2 Signatureo Applicant/Contractor Dau roof HAZARDOUS MATERIALS DISCLOSUREWill the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and SafetyCode,Section 25532(x)? Aroo :,shall be inspected prior to any roofing material being installed. 0Yes �'� If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or deviceswhich all new materials for inspection. L hazardous air contaminants u deft by the Bay Area Air QualityManagement .strict? 0 Yes o 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building does not currently have a tenant.that it is my responsibility to notify the occupant of the Date rcyuirc�enbr . toissuanceofaCertificateof ea Signature of Applicant 0 All roof coverings to be Class'J�.``or better Owner Dau CITY OFCUPERTINO WATER HEATER �� Ooh ' CUPE(,TINO PERMIT APPLICATION FORM APN # Date: Building Address: S 0 3 L,+- c--- C Owner's Name: Phone #: ff) ac�; oi rne- kA-ib '40�- asS- Contractor: Phone #: ( col 2s5 -713 Fax #: (,,,0 try-r-sa-L Cupertino Business License #: Contractor State License #: 6z -� 36 � Contact: Phone #: -Z?S7�_� 13 Cc � L� �� I•ei � 11 Fax M Building Permit Info: Bldg ❑ Elect ❑ Plumb Mech Residential ❑� Commercial ❑ Job Description: f� LACI Strapped On Platform a Bonded ) New Location ❑ Replacement Valuation (cost of project): 1C7- 0C) Project Size: Express Standard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Green Building Points achieved: Revised 01/07/09 y:.. CITY OF CUPERTINO WATER HEATER CUPEI�TINO PERMIT APPLICATION FORM Quantity Fee ID Fee Descript.on Fee Permit Type Group 1PCWHEATR Commercial Water B PCWHEATR HeaterNent 1BCBSC Cal Bldg StarLdards B ALL PERMIT TYPES Commission :-ee 1BSEISMICOM Seismic Commercial B 1 PRWHEATR Residential Neater B PRWHEATR HeaterNent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICRE Seismic Residential B 1 PPERMITFEE Plumbing Permit P 1 TRAVDOC Travel & B Documentation 1 BUSLIC Business License B Community Development 10300 Torre Avenue �f Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 -,UPERTINO Building Department JOB AI��R�S: 1 l�� C�- PERMIT #J OWNER'S NAME: YYb k,J hnc y,�ti fl PHONE # Yo - 05S- 13 6 GENERAL CONTRACTOR: 6 fr FAX # I am not using any subcontractors: ignature 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 Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date