09050115 CITY OF CUPERTINO
BUILDING DIVISION PERMIT S � }RMA. ......
BUILDING ADDRESS: PERMIT NO.
991 CRANBERR TBD_:- TO BE
PERMIT ISSUE DATE
OWNER'S NAME:
S A CONTROL NO.
PHO
BUILDING PERMIT INFO
.HITECT/ENGINHER: BLDG ELECT PLUMB MECH
0 o a 0
y p ZO LICENSED CONTRACTOR'S DECLARATION Job Description
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing
2Z� in fullSection
orcean effecDivision3ofdteBusinessand o ons Code,andmylicenseis RPLACE [S'I'R HTR- VILLA PLUMBING-GILROY PD FOR BUS
2 7 y in full force and effect.
Z License Class Lle' ` - , LIC 5/19/9
nF-p Date �i�+( -6 f Contractor
!� ARCHITECTS DECLA AT10N
C2< 1 understand my plans shall be used as public records
X96
L o y Licensed Professional
H OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
p o following reason.(Section 7031.5,Business and Profcscions Code:Any city or county
y^Pi which requires a permit to construct.alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation
E=,< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 )q
Y 1- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $1500
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars(5500). 36202037 . 00
❑I,as owner of the property,or my employees with wages az their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Conuactoes License Law does 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
sale.).
❑1,as owner of the property.am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and,
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec. B dr P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
--tion,as provided for by Section 3700 of the Labor Code,for the performance of the
tr for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy
number
Policy No.: O
Cartier. , '
CERTIFCTE
OF EXEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or Icss.)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so az to become subject to the Workers'Compensation
Laws of California.Date
Applicant
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
0 forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
[�►�-� I hereby affirm that there is a construction lending agency for the performance of
IYw> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q L.endces Name
�
Z
L.endees Address
U O 1 certify that I have read this application and state that the above information is
LL H COrtCCL I agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (We)agme to save,indemnify and keep harmless the City of Cupertino against
„.4 I;A liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. Date- ''t J�
APP UND RSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SO CE RE UL S.
_ � Re-roofs �—
S' nature o Iicant/Contrac or Data T of Roof
MATERIALS DISCLOSURE Type
W applicant or future building occupant store or handle hazardous material
az defined by the Cupertino Mu U"pal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes No If a roof:s installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? /
❑yc4 u
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health do Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
does not c ndy have a tenant,that it is my responsibility to notify the occupant of the
require ms w'
or issuarcc of a Ccrtificatepf Occ�t ry. e_ Signature of Applicant Date
Lr t
All roof coverings to be Class'W'or better
0 cr or au rind agent Date
CITY OF CUPERTINO �'v�D
WATER HEATER
CUPE(�TINO PERMIT APPLICATION FORM
APN # Date: _
Building Address:
9�,/ (t4,AA eA/<
Owner's Name: Phone #: �3._ 7 /
4
Contractor: Phone #O'Ct) S'of- q1O 2—
1/�" ✓ !� C`� �i2�. Fax
Cupertino Business License #• Contractor State License #:
lile
Contact: Phone #:
Fax #:
Building Permit Info:
Bld ❑ Elect Plumb' Mech []�'
Residential M Commercial ❑
Job Description:A110 144 le ` J/�..f
Strapped ❑ On Platform Bonded New Location ❑ Replacement
Valuation (cost of project): '
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
CITY OF C UPERTINO
} : WATER HEATER
6-CUPEf�T1NO PERMIT APPLICATION FORM
Quantity Fee ID Fee Descripti)n Fee Permit Type
Group
1 PCWHEATR Commercial Water B PCWHEATR
HeaterNent
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission F'ee
1BSEISMICOM Seismic Commercial B
1PRWHEATR Residential Water B PRWHEATR
HeaterNent
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission fee
1 BSEISMICRE Seismic Residential B
1 PPERMITFEE Plumbing Pennit P
1 TRAVDOC Travel & B
Documentation
1BUSLIC Business License B
Community Development
10300 Torre Avenue
y; Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
CUPE�TINO
Building Department
JOB ADDRESS: PERMIT
OWNER'S NAME: PHONE # 1(03J efyt--V16
GENERAL CONTRACTOR: / 4 FAX # syp -S-?c r
I am not using any subcontractors:
Si mature Date
Please check applicable subcontractors and com-,:)lete 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