08060176 CITY OF CUPERTINO -
BUILDINGDIVISION PERMITCON,°TRACTQRIN 'U,RMA�ION, :
k J?
PERMIT No.
"".?I %'9%RE5�EMPSTER AVE AFFORDABLE WATER HEATERS & 08060176
OWNER'S NAME: PERMrf ESUEDATE
TODD RUSSELL E AND MARGUERITE 24707 RAILROAD AVE 06/24/2008
NE:
SANITARY NO. CONTROL NO.
ARCNtfECnFNGINEE0.: - BUILDING PERMIT INTO
REPLACE WATER HEATER 40 GAL BLDG EIFCT PLUMB MECH
0 0 0 0
gooLICENSED CONTRACTORS DECLARATION GAS
herlob Description
C 1 hereby affirm Jut 1 un licensed under pmvisiom of Chapter 9(commencing
U wiNScefim70f10)af Dmslan3ofth Business and Pr fcuiav Code,end[ryy'Ikena is
s in full forte en 2�3 V
jmi License Cl a r� IJc.Y
F Da¢ 2 Conmcmr t.
AR Call be DELLA ION
I understand my plans hlWl he weal u public accords
JyU
g Licensed professional
5 OWNER-BUILDER DECLARATION
E I hereby arms that I an exempt from she Contractors Liecna Law for the
D o following redeem.(section 7031.5.Business add Prefecsinm Cale:Any city or county
$ff which requites a permit m cmnsuuc4 alter.impmw,dcmnilsh,er repair any suunure
Zz� briar m its issuance.Act,mqui.the applicret for such permit m file a signed nutemcm
< that he is licensed pursuant m the pnevisians of the Caanalms Lee=Law(Chapter9 Sq.Ft.Floor Area Valuation
YDS (commencing with section 7000)of Division 3 of tie Business and Professions Code)or
- that he Is exempt therefrom and the basis for the alleged saemption.Any violadon of
Section 7031.5 by ary appliamt fora pcomir subjects W applicant ina civil penalty of APN Number Occupancy Type
reps moa Jun ftw hundred dollars(S500).
❑1,u owner of rile propary.or my employee with wgn as Ncv sok emnpensaJon,
win doWsions Cadsh The Canunoes Lia Law
rut apply
Osseo Required Inspections
and property
who Cade:The Canuators rad who law dos Out apply m rt awucr is q P
p e am who Wildxmineprowa Nunn,and who daesstN work hkwdfm Waugh his
hoseemr.the a,pingor asommuhassuch improwmathas not soundedaralad forswun,
however.the building or improvement u hold within ane year of am ewc for she owury
builder orifi have the WNrn of proving that k did rot build or improv for purpose of
isle.).
0 1,as owner of the property,am exclusively contracting with licensed anwctars to
ansuuet the pmjen(Sec.7W.Business and prafevtie is Code)The Comaturo's U.
cents law does not apply to an owner of property who Wild,or Impress Wneon,and.
who contracts fm such projects wish a conmaepr(s)licensed pursuant to the Cantramr's
License law.
O larommieumbe Sec .B&PCfmthisaaon
Owner Dae
WORKER'S COMPENSATION DECLARATION
1 hemby alone under pevlty of perjury arc of W fallowing ducluatians:
1 haw and will maintain a Certifiau ofC...t m self-iwra for Workers Cmnp r,
talon,as provided for by Section 37W of the Labor Code,for the performance of the
work for which this permit is issued.
0 I have and will maintain Workers Compensation Insurance,m retained by Section
3700 of the labor Cede,fm the perfarmance of the work for which this permit u I..&
My Workers Com wtioo(W7 a�sena cancer and Policy number-
Gaffer. GK\YV
Polity CERTIFICATE
CERTIFICATE OF EXEMPTION FROo.�OVM WORKERS'
COMPENSATION INSURANCE
(Thihsenim need Out be complemd lithe permit is fame hundred dollars(SIM)
or less)
1 artily Wt in the performaotes of the wart for which this permit Is issad.l anal sur
employ any Noun in any manner so m to become subject to W Workers Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Cenincate of Exemption,you should
become subject as the Workers Compensation provisions of the labor Cods,you most
.,O foMwiLh comply with such provislons or this permit stall W deemed awkcd.
'Z 14 CONSTRUCTION LENDING AGENCY '
[-� I hereby arrm that there is a cortsuucdm Icieingigency far the peofum.of
C> the work for which this permit is hued(Sec.309'1,Civ.C.)
0 lenders Name
z fenders Address
U Q f softy That 1 have read Ws applicaian am suis Na the aWw informada is
DLH CO=L I agree m comply with all city and countyordinances and Grata laws relating in
V Wilding construction,and hemby wdroum mpasenmivns of this city m enter Open tic
aWw-mentiorted %cny far,. ..om puryova
F y (We)agree m saw,indemnify aced kap harmless W City of COpenina against
l,iZ in
of secoaUind oxpenua which ma yvny accrue &A.[said City
t1 z A APPLICANT
ofthegranting of n
^� APPLICANT UNDERSTAN D MPLY WITH AL NON.POINT Issued by: Date r-•G
SOURCE GUbrn{ON n � y /^�
(/ fI'
Siena lion r
NAZAADOUs MATERIALS DISCLOSURE�— Re-roofs Type of Roof
WIII Ne applicant m fMuni Wilding a.Chapt arc m haedlc Health
ematerial
C defined by 5 Cupertino Municipal Code.Chapter 9.12,and W HW N and Safety
Code, E3y.uct 25532(x)? All roofs shall be inspected nor to an roofing material beim
❑Yah e P P Y g g installed.
If a roof is installed without first obtainingan inspection,I agree to remove
Will W applicant or Talus Wildin aapant use equipmem or devices which P g
it haatahms A,emistra"ats a d d by the Bxy Arta Air Quality Management all new materials for inspection.
Dtavin7
SYu Nu
I have sal the havodws materials aItarene s;wamichaper6.95 arch Clan.
nu Health SafetyCodc.SmUT.$75505 533 and 25534.1 urukrstand If tie Wilding
Jaa mol hdw rR 'r yaaporuihili mnotif cpnl of the
a moments r aeaue afa r Oce Signature of Applicant Date
owner. a.......d,gcnt D,te All roof coverings to be Class'W'or better
CITY OF CUPERTINO
• 4 ITEMS OF 20 PERMIT RECEIPT OPERATOR: pdtg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . . 32648028 . 00
DATE ISSUED. . . . . . . : 06/24/2008
RECEIPT #. . . . . . . . . : BS000005201
REFERENCE ID # . . . : 08060176
SITE ADDRESS . . . . . : 10484 DEMPSTER AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER TODD RUSSELL E AND MARGUERITE
ADDRESS . . . . . . . . . . : 10484 DEMPSTER AVE
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1225
RECEIVED FROM . . . . : EDDIE D NALLEY
CONTRACTOR . . . . . . . : LEONCE ROUX LIC # 26850
COMPANY AFFORDABLE WATER HEATERS &
ADDRESS . . . . . . . . . . : 24707 RAILROAD AVE
CITY/STATE/ZIP . . . : SANTA CLARITA, CA 91321
TELEPHONE . . . . . . . . : (661) 259-7131
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 1, 700 . 00 0 . 50 0 . 00 ' 0 . 50 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1PRWHEATR UNITS 1 . 00 24 .48 0 . 00 24 . 48 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 106 . 56 0 . 00 106 . 56 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER
•
-� CITY OF CUPERTINO
08o C)i� - o
:. WATER HEATER
CITY OF
• CUPERTINO PERMIT APPLICATION FORM
APN #� - J�/ n a : 671) Date:,,,_ZY_0c7,_
Building Address: Q
joy8y DctM rster R✓k .
Owner's Name: Phone #:
1LuSSe�l road /otr- �5-1 - 91 as
Contractor: Phone #: 6,61- 1 Sq - 71 3 1
AFforcl able Wcgw F��AferS
Fax #: (clot 45-Sc
Cupertino Business License #: Contractor State License #:
�b 9'5'6 lo�-7 3(,K
Contact: Phone #: (,&I o Sa.o
Scott LifitleFf e Id
•
Fax #: (viol 96'S-6
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Residential N Commercial ❑
Job Description:
PeP1aee. ujccrer 14ater e(6 5co 5tis
Strapped On Platform ❑ Bonded 5?f New Location ❑ Replacement
Valuation:
1-700
Green Building Check must be completed and attached to this application.
• Green Building Points achieved: �'
.y Community Development
10300 Torre Avenue
Ft' Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
Oy$y Dzr. Srer 4 ,t¢ . 60 6/G 1 7
OWNER'SNAME: Ru5$zII pcA PHONE # 08 -457 IJ5-
GENERAL CONTRACTOR: er9stal-aWeI j FAX #
I am not using any subcontractors:
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