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05100180uec� pp ,z, = o iLLu o� +lay. EF`c i — 02 Z C CITY OF CUPERTINO ' ` rod, ; `" �,Zr,••t '"' BUILDING DIVISION PERMIT ,� &ON, 'CTOR I QRMATIA BUILDING ADDRESS: WATER HEATERS ONLY PERMIT NO 05100180 0092 TDEN OR ERS NAME: PERMIT ISSUE DATE GEORGE GARCIA 970 E 5 PHONE: SANITARY NO. CONTROL NO. (800)835-5946 ARCHITEC tENGINEER: BUILDING PERMIT INFO - BLDG ELECT PLUMB MECH 0 0 0 LICENSED CONTRACTOR 'SDECLARATION �q p0 Job e5,tTJttjV I hereby affirm Net 1 am IimnmO under provision of Chapter 9 (commencing with Sccuon )ofiU)of Divi ion3of NC Business and PruG.anns Code,am myliccuc is r i@Y/� mmn roma andef�ect,3� 7 Liecnu WATER HEATER Dem C/]1 GI 0. Cum r 'IsOI//� 1- 1 undcrswnJ my plana shall W a es puM1lic mcoNs - CO O✓ Liccnscd Pmfcssional OWNER -BUILDER DECLARATION I hereby affirm I oro exempt from @c Contractor's Law for thefollow enseAn, V fay w Co e: r maso on 703 ons Code: ray county p it whichir quires a. Permit t alter, ire rove, de air structure ommuelusineas impose. which requires olio re c�n ��"'+++ A $1000 0 0 0 h rwrmah, fie, a prior bs its issuance, also requires the the applicant for such permit m file signed eummcm n lithe pUmdant the provisions Mof Contractor's Liars Law(Chapter 9ock)at Sq. FL Floor Area "' Valuation (commencing encing wish Section7")it of Division of Business and Professions Coto) of (comma Nat he u exempt themfmm and the buts for Ne alleged cmmption. Any violation of Al MzRve-r UU Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of not more Nan Eve hundred dollars ($500). I, u ownu of the pmpcny, m my employees with wage ns their sole compcnsstinn, Required Inspections ale (Sm. Busin will do the work and the strucmm is not intended or offered for ess and Propounds Code: The Conoacmes Liave law does not apply to an owner of property who builds or improves thereon, and who dmssuch work himself orthmugh his own cmploycu, provided that such improvements arc not intended oroQarW for sale. If. a however. Ne building or improvement is sold within one year orcomplction. the owner. builder will have the burden of proving that he did not Wild m improve for purpose of sale.). ❑ h As owner of NG propeny, am exclusively contracting with liccued contractors to cunswct the project (Sec. 7614. Business and Profusions Code:) The Contractors Li- mine law does not apply to an owner of property who Wilds or improves thereon. and who contracts for such projects with a mammonist licensed puuuan0o the Conlractofs Lice. law. ❑ I am exempt under Sec. . B & P C for this mason cr Date WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a Ccnificam of Consent o self-insum for WohceaCompen- Morn, u provided for by Section 3700 of the labor Code, for the performance of Ne work for which this romit is issued. XI have and will maintain Worker's Compensation Insurance, as required by Section 3701 of the labor Cmc, for the performance of the work for which this permit is issued. My Worker' Cnto at Inxunnce canter and Policy no he am: I•gLSV3 �V Cartier. "icy'..; C tTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE fr oaseetitm nem not hs compined Jibe permit isforanc Wndmd dollars lSl00) or ksa) I eerufy that in time performance of the work for which this Permit is issued. I shall not employ any person in any manmrso As; to become subject to the Workers' Compensation Law of Califomia. Dam Applicant NOTICE TO APPLICANT: If, after making this Certificate of Esemption. you should become subject m the Worker's Compensation previsions of the labor Code, you most forthwith comply with such provisions or this permit shall W dttmed Evoked. CONSTRUCTION LENDING AGENCY I hereby Mo. that them iso construction lending agency ]or the perform. of the work for which his permit u issued (Sec. 3097, Civ. C.) Lender's Name ' Lender's Address 1 mnify that I have mad this application and sun that the above information is ' correct. 1 agree m comply with all city and county on inances and state laws relating to building conmmCLim, and hereby authorire mprescioadves of this ei ty to cnmr upon the above-mentioned property for inspection purpntet (We) .,me to save, indemnify and keep harmlesv Ne City of Cupenino against liabilities, judgments, costs and espenses which may in any way acerae against said City in conuquchre of the granting of this permit. APPLICANT U ERSTAN ANp-)VILL CO PLY WITH ALL NON -POINT :E RE ATIG Issued by: DateSO Aj •2, LO/y��oJ Re -roofs `� •'� Type of Roof Signature of Applimid/Comracmr Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building Occupant store or handle hnardous maorial by the Cupertino Municipal Code. Chapter 9.11, and the Health and Safety °•lion 25532ca>+ iolned All roofs shall be inspected prior to any roofing material being installed. ] Yea ❑Np If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future Wilding Occupant use equipment ordevicea which emit harardnus air contaminants As defined by the Bay Area Air Quality Management all new materials for inspection. Danko ❑Yes ON. I have mad the havaNnas mnmrials¢yvimments under Chapmr6.Y5 of the Glifor- nu HnaBh&SofctyCodc.S 6.25505.25533and25534.1undcnumth.ifthc Wilding have a Enank Nat it u m upomi�a M the docs not encs requirements whicnro wh pryF w' Ito ofaC froom o(Qcupanry. / Signature of Applicant Date ,uPr `mc isJ/i�(/E,• All roof coverings to be Class "B" or better Owner or au1Mrivcd' agent DS it Kid CITY OF �1PERTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax(408)777-3333 Building Department JOB ADDRESS: zav 5 2 9 p / � PERMIT # v-'it^.� [(/ d 5/ d o u OWNER'S NAME: c -9�' � PHONE # Z GENERAL CONTRACTOR: Qaw. xC a ,.JZ FAX # I am not using any subcontractors:4Z&, klka- . 04 Signature Date Please check applicable subcontractors and comvlete the followine information: n1L- A /a2/ oS Owner/Contractor Signature Date 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 n1L- A /a2/ oS Owner/Contractor Signature Date • Item 2 of 3 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 36934025.00 DATE ISSUED.......: 10/21/2005 RECEIPT ##.........: 31692 REFERENCE ID # ...: 05100180 SITE ADDRESS .....: 20092 JOHN DR SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OPERATOR: suem COPY # : 3 OWNER ............: GEORGE GARCIA ADDRESS ..........: CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4415 VOICE ID DESCRIPTION 502 FINAL PLUMBING ENERGY 507 FINAL PLUMBING O VOICE ID DESCRIPTION 506 GAS TEST RECEIVED FROM ....: BOBBI J PEMBERTON 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 502 FINAL PLUMBING ENERGY 507 FINAL PLUMBING O VOICE ID DESCRIPTION 506 GAS TEST 111 F WUPEkTINO F- L L CITY OF CUPERTINO WATER HEATER PERMIT APPLICATION FORM 0 5/0z>/&�5 APN # 7 /35� Date: 10/2/(U S Building Address: ZC) O Z / BUILDING Owner's Name: �_e vzy e-c.a Phone #: 25 2 - Contractor: / �� (� Phone: 8o0 £f3S-S9L/6 License #: 3-)gS73 Contact: Phone: _ Cupertino Business /License #: / 1 �O L Building Permit Into: Bldg ❑ Elect Plumb Mech Job Description: �u Residential Commercial ❑ Cost of Project: /00 U . CT -V trappedOn Platform Bonded El New Location EJReplacement Qty. if Applicable Fee ID Fee Desrrintinn P', rrn 1 BPWHEATER Water Heater/ Vent BUILDING 1 / PPERMITFFE BENERGY _ .Plumhing Pcrmil I.,"tiance E nerg y PLUMBING BUILDING BUSLIC Business License BUILDING