06030167 CITY OT CUPERTINO t«°a *�,"',
BUILDING DIVISION PERMIT ACONTltACT®R INi
.OR OLiMATJOI01�
BUILDING ADDRESS: PERMIT NO.
21589 EDWARD WY
R'S NAME: PERMITL4UEDATE
JIM LA FRANCHISE 970 E. MAIN ST, SUITE 200 03/29/2006
PHONE: SANITARY NO. CONTROL NO.
(800) 835-5946
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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boa
LICENSED CONTRACTOR'S DECLARATION Job Descri , ■�
1Wrcby goof that 1emftim Bounder provisionsPfuofCMper9(commencing N ��
with Sotiton]Ofp)tof Division Sof the Busiraas IProfeaslo CN m liccn 4
�n in full fmaand[frn � (o y .WATER HEATER
Lkease Cl v .
Da¢ ITEC1-SDECLARATION C
t� 1 understood h nd my puns dull usedu public recordsMAY 7-- 2006
5t; Licensed Professional
.3
OWNER-BUILDER DECLARATION BUIL
, B��(sy,�
.�a I I hereby
mOnm Nn 1 1. ,Bumps from the r Gtonpn"tort Liana Gw for the U e{V�j
ep o following moon. emtiun 71131.ru Business and ver,dctiuli Code:My oily or County (]
$tai which requires s permit.cnnstrveL elan improve,demoluh.m rcpasr any Iwcmm
poor In is Issuance,ala requimsthe applicant forsueh Permit o file a signed statement
< that he is licensed puruanlmthe provisions ofthoContioctur'sUccnselaw(Chapter 9 Sq.Ft. Floor Area Valuation
r�g (commencing with Section 7000)of Division Sof Ne Business and Pmr".ions CMLe)ar
Q —
that be is exempt th"efrom and the hub for the alleged exemption.My Actedon of "AA71 nn
Section 7031.5 by any applicant for a permit subjects the applicant to.civil penalty Of APR N-Liffiber Occupancy Type
not roam Nan Bw hundred dollus($500).
❑1.As.."of the property or myempldyeu with wages As their anacompenastion,
will do the work.and the mu"art Its not immmded or Offered f"We(SIL.7044,Business
and Poorest] Code:The Comescmr's License Law does not apply N an owner or Required Inspections
property w no builds or improves thermn,and who dos ouch wort hs,W f or through his
ownemploy es,provided that each improvements ser mttn2mled oroRertd for ease U.
however,Ne Wilding or improvement is sold within am year of Compaam.Ila owmr-
builder will have the burden of proving Out W did nm build or improve for purpose of
ask.).
❑1,As owner or de property.am exclusively contracting with licensed mnlncars in
Consumer the project(Sec.7014,Business;and Professions Code:)The Conlncmis Lf-
cane law does not apply b an towner of property who Wilds or Improves th"Con.and
who Contracts for such projects wits a eonmemor(q Ilomad pun ant u tk Conlracmre
Li,m m Law.
I A.exempt under See .B&PC for this mason
:r Dat
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury am of the following declarations:
❑I Morand will maintain aCeNrimmof Cowntuelf-imumf"Wo esCanpen-
sa0on,As provided for by section 3700 of the Labor Code,for use performance of tie
work for which this permit is issued.
I71 have and will maintain Workers Compensation Insurance,u required by Scetio
00 of the labor Code.for the Performance order work for which Na permit is issued.
My Workers. Compeas#n lnsunmx carrier and Policy nu r�:—��
Policy No.:
RTIFICA�irnON FROM WORKERS'
COMPENSATION INSURANCE
(Thb sombre coed not W completed if tui permit Isforr m hundred dollar($100)
ser la.)
I Certify that In the performance of the work for which this permit Is Issued.I Nall not
employ any person in any mannerso As An become subject to the Worker'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate or EamPtion,you should
become subject to the Worker.Compensation provisions of Ne LAWr Code,you must
.JO forthwith Comply with each prevision or Ns NW permit all deemed revoked.
Z r 0 CONSTRUCTION LENDING AGENCY
E Ihareby 1111.Nn siert b a Conurectim Leading agency for der perfurmamx of
E
the work for which this permit is issued(Sm.3097,Civ.C.)
QLand o s Name ,
u7. z lenders Address
V Q I certify Nu 1 have read this application and sate that the aWw infmmatiun is
p i F coned.1 as=to comply with all city and county ordinances and We laws muting in
Q C.) building Construction,and hereby authorie representatives of this city to enter upon flue
t1t ahove-mentioned property for impaction purposes.
(We)agree to ave,indemnify and keep harmless the City of Cupertino Against
..�fain liabilities,judgments,coats and expenses which may inany way acme against said City
U 7 in consequence of the granting of this pc I.
F7 APPLICANT UN RSTAND A LL CO Y WITH ALL NON-POINT Issued by: Date �• Zai'—ri G
SOURCE REG O ��
Slgnutorca Appli"nUGntrsm" 3Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne.ppliox t or future Wilding occupant mm,or studio Want..material
OFBrad by One Cupertino Municipal Code.Chapter 9.13.and tui Health and Safety
Section 25532(.)7
❑Y" gy� All roofs shall be inspected prior to any roofing material being installed:
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air conuminamf as defined by No Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes
I havc.W the huardous mamials requirements under Chapter 6.95 of Rte Califon-
.is Health B SafetyCodc,Sections 25505,35533 and 25534,I undersand thus Vat Wilding
doe not curtnntly how g tenant Net It b my rcapensihility a notify tui m[upanl of the
require Is hich must m" w isau f a Cc 'Mas of fkcupanc
W pa Signature of Applicant Date
OA < rat Daa All roof coverings to be Class"B"or better
• CITY OF CUPERTINO
Item 1 of 3 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 35619007.00
DATE ISSUED. . . . . . . : 03/29/2006
RECEIPT #. . . . . . . . . : 33787
REFERENCE ID # . . . : 06030167
SITE ADDRESS . . . . . : 21589 EDWARD WY
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : JIM LA FRANCHISE
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4764
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
FEE 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
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
acFax(408)777-3333
OPERTINO
Building De artment
JOB ADDRESS: aS S 9 Edjvm,4 �
0--j PERNIIT# a 603 m
OWNER'S NAME: _tyh PHONE # '446 — 37 (
GENERAL CONTRACTOR. " IFAX# p
I am not using any subcontractors: .9e, V"4 -1;1((
Signature T— 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
WATER HEATER (�30/(0�
CUPEkTINO PERMIT APPLICATION FORM
APN# 3 Date:
Building Address: ;;L t S-e `1 ��
Owner's Name: � y Phone#: 4 q-6 -3 7 6 $
Contractor;,.. Ph ne: License#:
9L� ?W S-591A 3 -744S -73
Contact: Q Phone: _ Cupertino Business Lense#:
Building Permit Info: a/
Bldg ❑ Elect ❑ Plumb Mech '❑
Job Description: d� -A 2 !�
Residential Commercial El a a�.>
Cost of Project: �qa r -D
Strapped El On Platform El Bonded El
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
I PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
•