06040160 CITY.OF CUPERTINO
BUILDING DIVISION PERMIT a���1N' �tACQIt'X� �`Tr
BUILDING ADDRESS: WATER HEATERS ONLY PERMIT N°'06040160
10170 CAMINO VISTA DR
OWNER'S NAME: PERMITLSSUEDATE
DAVID BLOCKUS 970 E. MAIN ST SUITE 200 04/26/2006
NE: SANITARY NO. CONTROL NO.
(800) 835-5946
ARCHITECUENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0p LICENSED CONTRACTOR'S DECLARATION - IOL)De3Ci1 U00
1 hereby aHhm Nat I am licensed under provisions of Chapter 9(commencing p
wl"cdon 7000)of Division 3 a(the Business and Professiam Cade,and my license is
in fall taros and L b 3 7 4 5 7 3 R&R WATER HEATER
j Pat Lt.... llay Lk.N
JJ4 Dme 7/J Contractor
yp ARCH SDECLj,RATJBp ^ FfN,�IED
�++++ I understand m kms useJrgyAfllCpfttLry49s�rrAr/�/
'co Lksued ProfmsnWl N
7ay OWNER-BUILDER DECLARATION
2<i I hereby alum that I am exempt from Ne Conumnfa License Law for the •� tp�QQ
"00 following mmm.(Section 7031.5.Business and Protea on,Coda:My city or countyI as
MAY 2�UU
which sn quires a permit construct,alkr.improve,demolish,or mpnir any monnum $900
3m�w prior m its issuance,also requires,time applicant for such permit to file a signedstatement
G that he is licensed pumunttothe provisions ofineConuacmr'sLianalaw(Chapter 9 Sq.FI.FI00rArea Valera
e� (commencing with Section 70D(BofDivislon 3orlWBusincas4nd Professions Cnde)or
that be is exempt thcmfmm and the buts for the alleged exemption.Any violation ofEM
Section 7031.5 by any applicant for a pencil subjects Ne Applicant w a civil penalty of r U pe
not mom Nan rive hundred dollen(5500).
❑I,u awn of tbe property,army employes with wain u their sok compeWNan,
willdothewark.Yid Neswmum is nalnteeded oranemd forMk(Sn.704l,Bwincss Required Inspections
and Profession,Codc The CmmAMm`3 License Law does sot apply n An owncr,of q p
property who builds or improves thereon,and who docMuch work Mmaelf or thmugh his
own amplaysn,provided Matsuch improvements aro nal intended oroRered for We.if.
hawewt the building or improvement is mid within ane you of completion.Ne=am-
build.will hew the burden of proving Wt he did not build or improve for purpose of
sok.).
❑1,as Owner of the property am exclusively convecting with Bttmed cooectors in
mmmuct the project(See.7044.Business and Professions Code:)The COMIAM rs U-
ceue law does tet Apply in an Owner of property who Wilda or Improves,thereon,and
who contracts for men projects with a contrecmr(s)licensed pummat m the Contractees
Lice=law.
❑I am exempt under Sea. ,B&P C far Nia moon
Owner Man-
WORKERS
ateWORKERS COMPENSATION DECLARATION
t1 Mmby affirm under parulty of perjury m of the fallowing declemalmm
I have and wgl mai.Wn aCenifrttm o(Connl m ulf-imam for Wark e,Compen-
sation,As provided far by S.W.3700 of the labor Code,for the performance of the
work for which this permit is issued.
700
1 haw and will melons.Worker's Compensation Imnu acquired quired by Section
of Jte labor Cods,for Ne parformantt of Me work for which this rm
permit is lamed.
My Worklies Compensation lnsmncm am."And Policy number Am:
Cartier. Policy No.: SO 3 _V q 9
RTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE v
Crhts sectme need not becompleved ifthe permit is forams hundred dollar,($100)
mitre.)
I certify that in the performance of the work for which this Permit Is issued,l shall oat
employ any person in my mannarm M In became Subject M tW Workers'CompenMdan
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this CCAIRCOM of EMMPMM,you should "
became subject in the Worker's Compensation provisions of Jere Lobar Code,you mot
� z forthwith comply with each provisions orthis permit mail Wdeemed revoked.
zO CONSTRUCTION LENDING AGENCY r
(..m Ibemhy amrm that NSM iso cansimeamn lending agency far Ne performers of
ai> the.,it fur which this permit is issued(Sec.3097,Civ.C.) '
aQ Landcea NYne
7 z Leaders Addrea
U0 I certify that I have read this application and sum Nu the am.Informed..is
IT.;-+ cartecL I agree to comply with all city and county ordinances and auk lam mlamin{te
0 Sl'J building convection.and hemby authorim representatives of this city to enter upon Ne
Is7 ahovc-mentioned property for inspection purposss
(Wc)agree to taw,indemnify and keep harmless Ne City of Cupertino,Calm,
,n ilmilides,judgmants,abets and expense which may In any my"ems against MidCity /
t.)z in consequence of the Comm this
Tmnni ��'Lt.7"Lam.
.. APPLI UND AND L COMPLY WITH AL NON-POINT Issued by: Date
SOU RE O 3.
ya Re-roofs
Signature of ApplicanUCommetor _ ow
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant or future Wilding aecupanismea or handle huaNaus materiel
As defined by that Cupertino Municipal Code,Chapter 9.11,and the Health and Safety
Code,Section 25532(a)?
[j Yen . All roofs shall be inspected prior to any roofing material being installed.
�N i
Will Nc applicant or forum building occupant vu equipment or Jcvies which If a roof is installed without first obtaining an inspection,I agree to remove
mil haymdnua air contaminants u dellned by the Bay Arm Air Quality Managemem all new materials for inspection.
District?
❑Yes
I have mot the hamrdousmekriah mquhemenu undcrchapkrb.95ofths Cali(ar.
ni.Hullh&Safely Cada Sectiom15505,25533am115534.1undcrsund NYifine Wilding
dean not c ly hew A krenL tis my rca mihilily m nctil'y Ne .pant or the
mgmrcma mah,'as Ire toimuan racemnaemar ey/ 'Signature of Applicant Date
Lt(w All roof coverings to be Class"B"or better
Owner m authorized agent am
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
:UPEkTINO
Building De artment
JOB ADDRESS: PERMIT#
. —10/ 70 Cciv r- ✓�tw 10ti P Yol6Q
OWNER'S NAME: PHONEr# l3 -'13 4'
GENERAL CONTRACTOR Q FAX l� #�
I am not using any subcontractors: 444 /�.c�a, nl, J L---
Signature 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
CITY OF CUPERTINO
�m 2 of 4 PERMIT RECEIPT OPERATOR: amyw
COPY # : 2
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 31214058 . 00
DATE ISSUED. . . . . . . : 04/26/2006
RECEIPT # • • • • • • • • • : 34149
REFERENCE ID # . . . : 06040160
SITE ADDRESS . . . . . : 10170 CAMINO VISTA DR
SUBDIVISION . . . . . . :
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . :
OWNER . . . . . . . . . . . . : DAVID BLOCKUS
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : BONITA JENKINS
CONTRACTOR . . . . . . . : MCGEE, PAT LIC # 18986
COMPANY . . . . . . . . . . : WATER HEATERS ONLY
ADDRESS . . . . . . . . . . : 970 E. MAIN ST, SUITE 200
CITY/STATE/ZIP . . . : GRASS VALLEY, CA 95945
TELEPHONE . . . . . . . . : (800) 835-5946
*EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BENERGY PERMIT FEE 1 . 00 34 . 86 0 . 00 34 . 86 0 . 00
BPWHEATER PER HEATER 1. 00 10 . 79 0 . 00 10 . 79 0 . 00
PPERMITFEE FLAT RATE 1. 00 38 . 37 0 . 00 38 . 37 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 84 . 02 0 . 00 84 . 02 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
____________________________ ___________-----------------
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
oLO040 ► �0
CITY OF CUPERTINO
WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN# 212 056 Date:
Building Address: /d l 7 D 0— 1 ✓- �
Owner's Name: n Phone#�
,.1� 73 _ 537
Contractor:/r, ' 1 Ph ne: License#:
!te/ ?W S-S'M 3 -7 Lt s 7 3
Contact: Q Phone: J _ Cupertino Business License#:
/9 9 9 6
Building Permit Info:
Bldg ❑ Elect E5— Plumb Mech *ET
Job Description: oe K ,g f
Residential 0 - Commercial ❑
Cost of Project: �y i
Strapped 7 On Platform �( Bonded15
New Location 13Re lacement y
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
I PPER v=E Plumbing Permit Issuance PLUMBING
I BENERGY Energy BUILDING
BUSLIC Business License BUILDING