06040117 CITY OF CUPERTINO xay, s Z '"
BUILDING DIVISION PERMIT „C•Q > RACTUR INFOJ,tMATIgNn�
BUILDING ADDRESS: PLUMB IN TIME INC PFAMITNo.06040117
1131 ELMSFORD DR
OWNER'S NAME: PERMITt$UEDATS
VICTOR HUANG 360 MEMORIAL DR STE 140 04/21/2006
NE: SANITARY NO. CONTROL NO.
(866) 293-3031
ARCHITEC fENO1NEER: BUILDING PERMIT INFO
BLDG 0 PLUOMB MOECH
3Op LICENSED CONTRACTOR'S DECLARATION Job Description
1 bomb, M.that 1 am licensed under pmviaiam of Chapter 9(mmmencus
with Section 7000)o'Dividan 3 of the Business Profession%Codo,md my license B REPLACE HOT WATER S TALL 12YR
tNN intmiltore,ane erceclt,,,� ��
ly
jylZ Licen.Class (' ��O
Lie.
i Jjip
Date_'tL= .p_CCIOSDEft._TON
l e(U i understand my plans NW W used u public records
IIICCCyg.
Licensed Professional MAY '¢— 2006
s�7 OWNER-BUILDER DECLARATION 0
I hereby alikm that I am exempt from the Conuamoes License Law for the
O O following reason.(Section 7031-1,Business and Pmfasiom Cate:My city or county $500
3$ which requires a permit to eonNrect,alter,improve,demolish.arepair my structure
2F a prior to its lssumcc,als r requires the appllemt for such permitto Rk a slpnetimmernm t
23� that W u licensed percent to the pmvisiona of the Contractors locos law(Chapter 9 Sq.Ft.Floor Area aluation
2 9 (commendngwiNScetiun7000).f Divition3or Ne B.sim..dPmr.i..Cadc)w
t, Out ha k nempt therefrom and the basis for ft alleged exemption.My vlalW,on of
Section 7031-1 by arty applicant to a permit subjects the applicant to a civil penalty of r U U Occupancy Type
not more than Bw hundred dollen($300),
❑I,u ownerof Ne ryoperry,or my mploym aW cages as thehmk ewnpewfion.
will do firework,and the strucum ism,intended oroncrcd forsake(Sec.7044,Business Required Inspections
and Prefeadom Cade The Contradars Lken Law doOwnere
es ret apply m an of 9 P
property who builds x im proves Nmnn.and wbo doca such vert himult or dunugh his
own employees,provided Nmsueh Improvements sure not intended oroRe.d for sale.It.
however,she Wildimgor Mprovsment is old within am yco of complefies.the owner-
builda will haw the WNev of provin'that W did not Wild or improve for purpoa of
ask.).
Cl 1.u owner of ted Property,too aseludvely contracting with 0cmued contractors be
convent tho project(See.7044,Business and Proresaioto code:)The Cmmcmrs Li.
cove Law does not apply m an owner of property wed Wilds or improve desmn,and,
who contracts for much project/with amnuanar(s)Bxned purmant to Ne Contractors
License Law.
❑I am memo,under See .B&P C for this mason
Owner Dau
WORKERS COMPENSATION DECLARATION
I Wreby,afBm under Penalty of perjury uses of the following dalanuioru
1 haw and will mainWn a Ce dn=ofcoment w wlf-im m fwworw3 Compcn,
satmn,as provided for by Section 3700 of the Inbar code,for the Performance of des
work for which this perml,is Wood.
❑1 haw and will maintain Workers Compensation Insurance,as required by Section
3700 of the labor Code,for the performance of the wrk for which this permit is imuct
My Worker ommmunion Insurance carrier and Policy number m:
Cama: Poliry No.: 'W Z144 N
L
CERTIFlGTE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tffi mcdao need mtbecanpkmd lines permit Is foram hundred doW m($100) r
orlesa.)
1 certify that in the peRomasce of 1W work for which this permit u Wound,l Nall nor
employ any person in my mmnerm as u became subject to the Worland Compensation
Law of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Cer ificau of Exempum.you should
bmmme subjeet be the Worker's Compensation prevision.of des Labor Code,you most
.J O forthwith comply with such provisions or Nu permit shall W deemed revoked.
,zr0 CONSTRUCTION LENDING AGENCY
[ti l herebyallirm that t.k•construction lending agency far the Performanm of
a> Ne work fur which this permit k bused(Sec.3197,Civ.C.)
Win~. Landers Name
z lenders Address
U Q I cenify that I have rad this application and sum that the show information Is
D.;^ coma 1 agree m comply with dl city and county on inarrco and sets lawt.INns to
0E Wilding contraction,and W.by mNodce representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
C>» (We)agree to save,indemnify and kap homeless the City of Cupertino agaimt
rw y Ilabilitica.jud5menu.eau and expenses which may in my way attTw against said City
t)Z In consequence of fies grmfing of this permit. ,a/
'-" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 4i� GO
lr
SOURCP R ULATIONS.
A4 ct_a..� �---Q-Q-- - 4-2-V-L('o Re-roofs /L_�
Signature of ApplicandComrmur Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will des applicant or future Wilding occupant seem or handl hauNom material
as dented by that Cupertino Municipal Code.Chapter 9.13.and des Health and Safety
Catio.Secfiom35532(.)7 All roofs shall be inspected prior to any roofing material being installed.
yes 5kNo
Will the applicant or(alum budding Occupant tan egnipmen,or device.which If a roof is installed without first obtaining an inspection,I agree to remove
nth Woodcuts
temi
r conumucts as de0the ned by Bay Amo Air Quality Man ,age... all new materials for inspection.
District? f
❑yes RHO
I haw mad the hasardmemmriatsrequirements under Chapter6.95 ordes Califon
nia Heal"S.fuy COde,Seetiau35503,25533 and 25534.1 uhticmatW NatlNes building
dum not ewrendy,have a inns s.that It is my responsibility as notify des occupant of des
regmrements wnkhmuu W mtoormisamnceofa Ccni0catear Occapmcy. Signature of Applicant Date
�� �4� All roof coverings to be Class "B"or better
Owner or tulhorixed agent Dam'
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRESS:' 1 1 D S PERMTTG G
Ute- L- / 0l� "7
OWNER'S NAME: PHONE # 40 - '777-02-41
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: L- '?�-
Signature Date
Please check applicable subcontractors and complete the following information:
60 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 1 of 5 PERMIT RECEIPT OPERATOR: amyw
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 36208013 . 00
DATE ISSUED. . . . . . . : 04/21/2006
RECEIPT # . . . . . . . . . : 34084
REFERENCE ID # . . . : 06040117
SITE ADDRESS . . . . . : 1131 ELMSFORD DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : VICTOR HUANG
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4901
RECEIVED FROM . . . . : PLUMB IN TIME
CONTRACTOR . . . . . . . : PAUL HENDRIXSON LIC # 27607
COMPANY . . . . . . . . . . : PLUMB IN TIME INC
ADDRESS . . . . . . . . . . : 360 MEMORIAL DR STE 140
CITY/STATE/ZIP . . . : CRYSTAL LAKE, IL 60014
TELEPHONE . . . . . . . . : (866) 293-3031
SEE 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
i
CITY OF CUPERTINO
WATER .HEATER
• CUP ( TING PERMIT APPLICATION FORM
APN Date:
3(02 -De -b►3
Buildi g Address: , �/ yis��
Own 's Name: r r Phone#:
�i ri1 YX Xl
Contr ctor: License#:
Cont a t: `` bl
Y 'o ,I b� Cupertino Business License #:
Buildi g Permit info: (0
Bld ❑ Elect Er Plumb 8- Mech O
Job D scription:
Resid tial '❑ Commercial ❑ ^'
Cost o Project:
od
Strapp d On Platform �{ Bonded
• New cation ❑ Replacement�l
Qty. if
A li able Fee ID Fee Descri tion
BPWHEATER Fee Gro
Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Ener BUILDING
BUSLIC Business License BUILDING
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