05110056 CITY OF CUPERTINOR
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
SUII,DINGADDRESS: GREEN FIELD PLUMBING PFJiMffNO05110056
194d5 GREENWOOD
OWNER'S NAME: PERMIT ISSUE DATE
LORETTA JEW 3513 MADRID DR 11 /10/200r,
NE: SANITARY NO. CONTROL NO.
(408) 946-5150
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
iOp LICENSED CONTRACTOR'S DECLARATION 0IOb Description
1 hereby afRrm Nnal 1 am licensed un (m
der provisions of Chapter 9 mmcncing
With Semon]")of Division 3 of NC Business and Professions Code,and my license is
inmufnaeaodeir¢, L m I� REPLACE HOT WATER HEATER
j,n_ Lkcuc Clue c
�Fct Dao: ContrmWr
ARCHITECTS DEC ATI N n
z-s I undersand my plans shall be used as public mcmnE 1
SyU
G y Licenced Professional
5 Oat I am oU rep,from
DECLARATION
y9 1 hereby.(term on I I. ucmpt Irem Ne Contractors LiAny c Law for the
tl O o following ea-n. emit u 7 onsur Business np Pmrcatlum Code:Any city s county
<m which requires a Permit to canswc4 a1Wr,improve.dcmoliN,or repair any structure
$500
pri.rm iaissuenee.alcurtquims lbeappliaaulforsuch permiholik.signedssa¢mem
Nalbe ulWcnWdpursuam to Nc provisions of Cm Conuxmh LJ¢M1e lsw(LTaptv9 Sq.Ft. Floor Area Valuation
yH� (commencingwiNS don7M0)of Divuion3af Ne Businmmd Professions Cnde)ur
y
that k Is exempt derefrom and the beau for the alleged exemption.My violation of
Section 703"by any applicant for a permit subjects the applicant to a civil porosity of "A?f*MriiiWerUU Occupancy Type
not more than rive hundred dollars(5300).
0 1,as owner of Ne property,v my wP],.with wages as their sole compeva0on,
will do the work,and the swnure u not ineMed or offered for ale(See.7(144,Business
and Pmfcssians cone:The Contactors Lime rU.es dons not apply f rt owner of Required Inspections
property whos provided
viemphasesen improve who d¢aamhwork himxl(m through his
Own employers,provided that men impmwmentsarenot ear.fUdoffered fwdcthe wo If. /
bowder.the building serimn Of prontumidwithinurcyeas orinteri forNeowrcr-
buil&r will haw the busdm of pharing that he did-t build m improve for purpose of
sale.).
1,as owner of project
property am Business
inus and crffessi ng with:)The Cmmrecess -
Construct La the es not (Sec.]044,weer and Prof ho Wilds
Cade:)The Coneanor's Li-
cense Law doss not apply a an owner of pra tortywho builds rs improves;Centro.and
who concocts fm such pmXcts with a crnuacWCs)licensed pursuant to the Contractor's
License
Ioro exempt under See .B9PCfor this mown
Owner Due
WORKER'S COMPENSATION DECLARATION
1 hereby fm under pnulry,of perjury me of Ne following declaration:
1 him and will maintain a CertiftoW of Consent W elf-insure for WorkctsCmnpen-
7017'W
tion.ssprovided for by Section 3]00 a(Ibe labor Code.for Ne pertarmm¢of Ne
rk for which this permit is issued.
i have and will main m Worker's Compensation Insurance,as required by Secvon
of the lobar Cade,for Ne peoporm.n.of Ne work for which Nis permit is issued.
yWorker'sCompensaGanreer: T( °& oliry No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tbu section need not he Composed if the permit is formic hundred dollars(SIM) '
Or has.)
1 certify Net in the poff.rmancc of de work for which this permit is issued,I Nall not
employ any person in any man-rut as W become subject W ISM WmIWn'Crmpcnsstion
Laws of CJifomia.Due
Applicant
NOTICE TO APPLICANT:IL after making this CerfirWae of Exemption,you shruM
become subjen W the Worker's Compensation previsions of the Labm Code,you mot
.J O forthwith comply with such provisions or Nu Permit Shu]be d emed mwkcd.
z' CONSTRUCTION LENDING AGENCY
[-. 1 berehy affirm that Vert Us construction lending age-y for the pertunna-c of
y' IM work(or which this permit u issued(S¢.3M.Civ.C.)
4 0 Undies Name
z Lender's Address
U 0 1 certify that l have rood this application alta sue that Ne above information u
[" correct 1 agree W comply with all city and county ordW-n and sure laws elating to
0 V building comrtctum.and hereby aathoriae epeacnudws of Nu city to cner upon the
&how-mentioned property for inspection pur osea
CL (We)agree to nave,indemnify and Map harmless Ne City.(Cupertino against
(� liabilidesjudgments,costs and expenses which may in any way sesmeagaiut said City .
U z in Ustruce,tatec.of the granting of this permit-
APPLICANT
ermitAPPLICANT UNDERSTANDS ND WILL COMPLY WITH ALL NON-POINT Issued by: Date —/O —p 0`
. SOURCE REGUT�-TIONS. _
//i 41- /o• 01Re-roofs ✓ —
Sig
vW Appton rm., Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupanumrc Of hroulk hvareous material
as defined by the L'Uperti-Municipal Code.ChapWr 9.17,and the Health and Safety
otic.Section 35333(4)?
0y. MIN. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or&vices which If a roof is installed without first obtaining an inspection,I agree to remove
Mit hnsrdmU air contaminants ss defined by the,Bay Arca Air Quality Management all new materials for inspection.
Disrict?
❑Yo ,'[,V"u
I haw reM Ne hvaldmumaWrials rtquiemcnu un&r CMper fi.95 of de Califon
nia Health&Safety Co&,Seedmu25505.15533 and2 534.1 un&sand Ns if Ne Wilding
dues nOl CurrenllY haw a W911t.Nal It La my let Nihit ity W-dry de,o cupNt of Ne
mquiromenu which roue/� P'or W tssu maccrficamoractpanry. Signature of Applicant Date
owmermra enl v/ fef `�.�� All roof coverings to be Class"B" or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT #
( q M4- .
OWNER'S NAME: IPHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: 1" � o 1777 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/Contract r Signature Date
CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: kiersaw
COPY # 2
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37504030.00
DATE ISSUED. . . . . . . : 11/10/2005
RECEIPT 4. . . . . . . . . : 31915
REFERENCE ID # . . . : 05110056
SITE ADDRESS . . . . . : 19415 GREENWOOD DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : LORETTA JEW
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . CA
RECEIVED FROM . . . . : GREENFIELD PLUMBING
CONTRACTOR . . . . . . . : TOM TRAN LIC # 23380
COMPANY . . . . . . . . . . : GREEN FIELD PLUMBING
ADDRESS . . . . . . . . . . : 3513 MADRID DR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95132
TELEPHONE . . . . . . . . : (408) 946-5150
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
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ____________ __________________
CASH 84 .02
TOTAL RECEIPT 84 .02
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
________ _______ ________
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
CITY OF CUPERTINO OSS DD 510
WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
3 ✓ - C)4
Building Address:
�efo LJ O0
Owner's Name: I Phone#: Z
Fir
-LE Lt1 I b7
Contractor: Phone: License#:
— S O
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect Plumb Mech C]/
Job Description: _
Residential Commercial ❑
Cost of Project:
p c�
Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replacement W,
Qty. if
Applicale Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING