08080169 CITY OF CUPERTINO xwm
UUILDING DIVISION PERMIT CONTRAOt R�INF0r' TA 'IONS :
BUILDINGA DRESS: PERMIT NO.
/',3 / K.LRWTN LN AFFORDABLE WATER HEATERS & 08080169
W NER'S NAME: PERMIT ISSUE DATE
SiItNOBU MATSUKA 24707 RAILROAD AVE 08/22/2008
PHONE: SANITARY NO. CONTROL NO.
(661) 259-7131
ARCHttECryENGINEER:
BUILDING PERMIT INFO
BLDG ELECr PLUMB MECH
0 0 0 0
On Z' LICENSED CONTRACT'OR'S DECLARATION
rd 1 bercby a(Rrm that 1 are lixrucd under previsions of Csapter 9(commencing Job Description
n withSalion700(fafDivision7aflhe Businsmand Pmfesumns Cade.md my 0eenois REPLACE WATER HEATER (GARAGE)
pZ in full fame and If 6773("6
j�� Lissom Clay IY.Y ••
n�p Da¢ Contactor t.�R
7W ARCHITECTS DECLARATIK-ON
aU I estimated my plain shall be usual as public resorts
go Ins Licensed Pmfessi...I
7 3 OWNER-BUILDER DECLARATION
i1 hereby affirm that 1 am exempt from the Connor's License law for the
00 following mason.(Section 7031.5,Business and ProhmWOM Code:Any city or county
$f which m9u4es a permit to construct,alter.improve.demolish.m repair any sw.ure
se poor b it issuance,also requites tib applicant for such permit to file a signed summent
< that he u liceded pursuant b lM provisions of the C.mranor's Lien.¢law(Chapbr 9 Sq.Ft.Floor Area Valuation
X�n (commencing with Section 7000)ofDivision 3 of the Business and Pmfeniem CtWe)er $1700
.- that he b exempt therefrom and Ise basis for the alleged exemption.Any violation of
section 7031.5 by any applium for a permit objects the Applicant In a civil penalty ofNumber Occupancy
not mai than fixe hundred dollus(5500). 3 5 92202 6 . P Y Type
❑1,u owner of the property,or my employees with wages a their sok compensation.
will do the work,and she stomm e is not Warned or offered for sal,(sec.7019.Business
and Pmressiom Cade:Th,Caancbrs License Law does Out apply to an awn.of Required Inspections '
Property who Wilda or im pmwa therms,and who das s uch work himself or tiuough his
owaemploYens,provided thalssch improvements are mat inrerldon oralf.eE for ale ff.
however.Ne building or Mpmvement is cold within arc yes of completion.the owner-
builder will love the herds of proving that as did not build or impress mor purpose of
sale.).
1,as Owner of the property.am mcholvelY contracting with licensed contractors to
Outmost the Project(Sce.7050.Sesames and Pmressiom Code:)The Conmemr'a U- -
cerue Law dun not apply to an Ownrr of property who builds or impmvs themm.and.
who concoct for such projects wit a conncbr(s)Remand pursuant to the Con seer's
Lice.law.
I"a cam",under See .B h PC for Nu reason
Data
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penally of perjury,aro of the following declarations -
❑i ham aM will maintain a Ceruftorear Comcat b se)NOsom for Worker's Compere
smon,as provided for by Section 3700 of the labor Code.for the performance of the
work for which the permit is issued.
❑1 Mss and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Code,far the performance of the work far which this permit is instal.
My Workeel mpentdon Ivunnce carrior and Policy number ma
Carver: �•• 1�.. Posey Na:24 fob$55'7 Ot
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This sutim seed embe completed ff tam permit isforum hundred daOva(5100)
or less)
1 certify met in the Performance of tic work for which this permit is issued.I nonI not
employ any Peron in any manner to a b become object to the WoM1 Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT.If,after making this CeniOote of Eaemption,you should
became subject m the Worker's Compensation prevision of aim labor Cade,you must
.,O forthwith comply wit such provisions or this permit shall 6,daemon cooked.
z "' CONSfRUCT10N LENDING AGENCY
[—i.�. 1hereby snare that there is a construction lendingfor Use dormaas of
a.) P
C' Ne work for whits esus permit Is issued(Sec.3097,Civ.C.)
ALender's Name
D Z Lender's Add^..
U 0 1 certify that I base mad this application od sub that the above information Or
say correct 1 ogres b comply wit all city and county ordinances and sum laws relating m
C) Wilding conduction,tib hereby amhodet MPO Oselmi es of this City m enter upon tib
shove-menuaned property for impecvon puryosea
F 4 (We)agree to save.iMemnify and trip hamalet db City of Caption.against
t,lZ in s.
ofthecuuaonof th' swhich may in any wayamuc agalnstsvd City
t)z A APPLICANT
of the granting of this no y�
^ APPLICANT UNDERSTAND D ft COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REG S.
Signature.f Apptrat✓Canwnur Dab Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building MCITI ntsbm u handle Isms d.us material
de0md by the Cupertino Municipal Code.chapter 9.13.and the Health and Safety
. 0T.n2ss3z(o7 All roofs shall be inspected nor to an roofing material beim
❑Y. Na P P Y g g installed.
If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicant or'mum b mg occupant use equipment.r devices which P g
caInt hcr�m air mnwninant road by Ne Bay Area Air Gustily M...gcmrnt all new materials for inspection.
❑Y. N c
1 have mad the btallot mamrlais mquiremcnuuader Clupmr Q95 of the Calilm,
iia Health&Ssfcty Cods,SCNoas 25505,2 )Jost 25334.1 undemmnd that ifth,buil ding
da.ret curten11 haus wool.th.Jt-6mY r.portubililY b notify tic escaper,of err
myuimmcnu wh' us be mel r ass or,r.n;fieab era Signature of Applicant Date
L�te
Owner u authodo0 agcm Data All roof coverings to be Class'W'or better
' '
-� CITY OF CUPERTINO
WATER HEATER
CITY OF
CUPEIITINO PERMIT APPLICATION FORM
APN # � DU Date:
Building Address:
V-i rw i V1 UNu--
Owner's Name: Phone #:
ShIi " ou Y�at,�1LlU,� 40VI,(ol 7
Contractor: Phone #: (,6I- 15-1 - 7 1 3 1
f}Ffordable W4W 142aferS
Fax #: 661 - 1Sy - 9SSc
Cupertino Business License #: Contractor State License #:
�6kS0 6 -'7369
Contact: Phone #: 6G1 - j59. 0 sd o
® $cotfi LitfileField
Fax #: (061 -4-6-1- 9sS6
Building Permit Info:
Bld ❑ Elect ❑ Plumb Nf Mech ❑
Residential N] Commercial ❑
Job Description: j�„ ,,,1 a u- w� tv , p „ _I ���
l��iJ 6 �' 14(/ u� riV
Strapped �] On Platform ❑ Bonded Yr New Location ❑ Replacement
Valuation:
Green Building Check must be completed and attached to this application.
• Green Building Points achieved: -OL._
CTTY OF CUPERTINO
WATER HEATER
CITY CII
CUPERTINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCWHEATR Commercial Water B PCWHEATR
HeaterNent
BSEISMICOM Seismic Commercial B
I PRWHEATR Residential Water B PRWHEATR
HeaterNent
/ BSEISMICRE Seismic Residential B
I
PPERMITFEE Plumbing Permit P
TRAVDOC Travel & B
r Documentation
BUSLIC Business License B
•
Community Development
10300 Torre Avenue
✓' Cupertino CA 95014
Telephone(408) 777-3228
*CUPEk�TINO Fax(408)777-3333
Building Department
JOB ADDRESS: PERMIT #
5-72 ki ('w,;w C.AIJ &Oj--6 (6
OWNER'S NAME: St, Ie o PHONE # 1/6-- 6 o- ) 2
GENERAL CONTRACTOR: W J}A F . #
I am not using any subcontractors: 712-2 .0
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
Owner/Contractor Signature Date
• CITY OF CUPERTINO
4 ITEMS OF 24 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot: .
APN . . . . . . . . : 35922026 . 00
DATE ISSUED. . . . . . . : 08/22/2008
RECEIPT # . . . . . . . . . : BS000005866
REFERENCE ID # . . . : 08080169
SITE ADDRESS . . . . . : 7572 KIRWIN LN
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : SHINOBU MATSUKA
ADDRESS . . . . . . . . . . : 7572 KIRWIN LN
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4339
RECEIVED FROM . . . . : EDDIE 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
FEF. ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
--—- ------ ------ --- --------- ---------
..BSEISMICR 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
7.PRWHEATR UNITS 1 . 00 24 . 48 0 . 00 24 . 48 0 . 00
ITHAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
---------- ---------- ---- ----------
TOTAI., PERMIT 106 . 56 0 . 00 106 . 56 0 .00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER