08090122 BUILDING DIVISION PERNUT C®NIRA CTSQ-'R INTORMATIgN ,
BUILDING ADDRESS: PERMIT NO.
10775 LA RODA DR FAST WATER HEATER 08090122
HER'S NAME: PERMIT ISUEDATE
JAN EDBROOAE 12601 132 AVE NE 09/18/2008
PHONE SANMARY NO. CONTROL NO.
(800) 454-8955
ARCHITECT/ENGINEM BUILDING PERMU INFO
BLDGELECT PLUMB MECH
0 t 0 0
go, LICENSED CONTRACTORS DECLARATION Job Description
4 u 1 hm Nw n
ereby affirm I lissed under provision of Clop er 9( m
comrxing
_I., with section 70(1))ofDivialon 3 of Ne Business and Professions Code.and my license is RMV/RPLC GAS WTR HTR
in full forte ane effect.
j i License Clan Ir'.6
=p Date Contractor
Fq77WW understandARCHITECTS DECLARATION
f W U I undmand my pians shall be tieu re
d public cords
L
Licensed Professional
5 OWNER-BUILDER DECLARATION
f 1 hereby affirm that 1 am exempt from Its Contractor's License Law for tM
i.0 C following reason.(Seeds.7(n 1.5.Bushman,and Pmfeviau Code:Any city or county
which requh=a permit to construct,slot.knpro`a,demolish.or repot my motion.
Prim as its issuance.elm"chat the applicant for such permit to file a signed statement
E�G that he is licensed prursuanuo the prevision of the Comrumri License Law(Chapter 9 Sq.Ft. Floor Area Valuation
�( $ (commencing with Section 700))of Division S of the Business and profession Coda)or $449
(� that be u exwpt therefrom ane the bobs fm the alleged eamnption.Any violation of
Section 7031.5 by my applicant for a permit subjecu to,applicant to a civil penalty ofNumber Occupancy
cot mane than five hundred dollars(SR10). 36934036 ., 3YPe
0 1,u owner of tha pmpmy.m my=ploy=with mga u eeh micwmpe=don,
will do Newark,and W abuctme 4 fiat intended w offered far sale(Sec.7014.Business
and Profession Cade:The Conuacor's Licutse law d=an,apply in an owner of Required Inspections
Property who builds m ire prows Nunn,mal who does much wok Aimnel(m tiuovgh his
awn employ=,provided that each improvements are not ina:ndW interfered for sale If.
however,the building in improvement Is mid within ane you of complNan,the owner- m
builder MB have the 4u hon of proving that he did rot Weld or improve fm purpose of
sale.).
❑1.u owner of the property w exclusively comuling with lined eca m=to
conswct the Project(Slot.7044.Business and Profassions Cade)71e Cunumm's LL
cense Law don not apply man owner of properly who builds m improves thereon,and
who contracts for such projects with•eamatem r(s)licensed punuaml to the Canueetote
Llano law.
�lamawptmder See ,BRPClmthiamwon
n Dae
WORKERS COMPENSATION DECLARATION
1 hamby air=under penally of perjury ane of Ne following declarations:
0 1 have and WI maintain a Cmdfmoaf Covent to self-iamrt for Worker's C=pen-
cation,an provided for by Section 3700 of the labor Code.for the performance of tic
wart for which this Permit is issued.
❑1 have and will maintain WorkCs Compensation Insurance,as required by Secam
37a0 a(rhe labra Code.for the Pmformeme.f the work formich this permit u Issued. -
My Worker's Compmuation mutant carrier and Policy n=bat ate:
Onix Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Mis sccdm need act he completed if rte permit is foraoe hundred dollars($IW)
or leu)
Ifortify that le Nap r..of Ve work fm which Nis pe=It uissued.1 slWl run '
employ any person in my cancer as us became subject in the Workers'Compensation .
Laws of California.Dao
Applicw
NOTICE TO APPLICANP.If,afmr making this Cm,ifrwte of Excmptor.you should
become subject m the Worker's Campensetion previsions a the,Labm Cade you mato
.Jz forthwith comply with such provision or tMs Permit mail to doemW mwkcd.
H CONSTRUCTION LENDING AGENCY
[-•s s� hereby affirm Nat Vert u a compromise lending agency for the perfwmana sal
Ili .moi thc work for,which this Permit Is Wood(Sm 3097.Civ.C)
0 Undoes Name
z Lender's Address
V C) 1 comely that 1 haw usd this wlmmon and sum that the above wrormatiue in
GL.L� coned I agree N comply with all city and comfy ordinances arta state Iowa mladng be
.O P, building conswttion.and hereby authadm rtprexntatives crisis city o anter upon to
Eon
property for inspection which ma
F D. (We)agree to save,indemnify and keep harmless the City of Cupertino against
V1 inconses,JWgmenheIssue itestimatesthis pewhich may in any wyamue against said City
C)z in eonsequerce of the Lrantint of Nu pewit
✓-m APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9
Date
SOURCE REGULATIONS.
Signature al ApplicaOr Dain Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicantmfuture Wilding acovpantamorem handleHeaAonmaterial
or
u defined by nin
Cupee Municipal CaOap
Cook, mr 9.13,and the Health and Safely
.sen25ium zss3z(.)?❑Tn ON. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building euvpam ate equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit lo-s men sir cmurainanu u defuoe by the Bay Area Al,QtWily Management all new materials for inspection.
District?
❑ya ❑Nu
I have read the hanrdun materials requirements under Chanter 6.95 of the Calton.
nia Health&Safety Cade,Sections 25505.25533 and 25534.1 understand that ifthc building
data nal cummuy have•rant that it is my respansfbiti y in sooty the occupant or Ne
requbremcnu which seep he met prior an because of a Cmefeste of Occupancy.
Signature of Applicant Date
owner arantharivee agcnf D,te All roof coverings to be Class'W*or better
CITY OF CUPERTINO
• 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36934036 . 00
DATE ISSUED. . . . . . . : 09/18/2008
RECEIPT # . . . . . . . . . : BS000006128
REFERENCE ID # . . . : 08090122
SITE ADDRESS . . . . . : 10775 LA RODA DR
SUBDIVISION . . . . . . :
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : JAN EDBROOAE
ADDRESS . . . . . . . . . . : 10775 LA RODA DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4443
RECEIVED FROM . . . . : 'JEFF JORDAN
CONTRACTOR . . . . . . . : JEFF JORDAN LIC # 29100
COMPANY . . . . . . . . . . : FAST WATER HEATER
ADDRESS . . . . . . . . . . : 12601 132 AVE NE
CITY/STATE/ZIP . . . : KIRKLAND, WA 98034
STELEPHONE . . . . . . . . : (800) 454-8955
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 449 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1PPERMITFE FLAT RATE 1. 00 40 . 79 0 . 00 40 . 79 0 .00
IPRWHEATR UNITS 1 . 00 24 . 48 0 . 00 24.48 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 .79 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 106 . 56 0 . 00 106 . 56 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 106. 56 VISA
---------------
TOTAL RECEIPT 106 . 56
_ VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER
•
16582
Permit No:Okoq 01-- SX4
(office use only)
• City Of Cupertino Building Permit Application
E-Mail: Building-Permits(d)cupertino.org (Address is case sensitive).
Jobsite Address:10775 LA RODA DR Date: 9/18106
Assessor's Parcel Number.,3(p Y,-3YOl(o , OU
Owners Name: EDBROOAE, JAN Phone No: (408)725-0438
Project Valuation: 449.00
Building Permit Info: Bldg_ Elect Plumb x Mach
Job Description
Remove/Replace Gas Water Heater
Contractor Information
Company Name: FAST WATER HEATER COMPANY Phone No:
• Contact Name: Carol Rendall Fax No: Boo-454-8955
Address: 12601 132ND AVE NE E-mail:carolr@fastwaterheater.com
City, State&zip code: KIRKLAND, WA 98034
State Contractor's Lic. No: 877489 Expiration Date: 5/31/10
Worker's Comp No: 1761660 Expiration Date: 12/1/08
Carrier Caiffornia State Fund
City of Cupertino Business License No: 29100
Credit Card Information
Credit Card No: 4417123041349530 Expiration Date: 11/10
Name on Card: Jeff Jordan
Visa ® MasterCard ❑ American Express ❑
The Building permit application and a completed &signed
• contractor/subcontractor form need to be submitted with each pernilt.
NOW
Community Development
10300 Tone Avenue
0
Cupertino CA 95014
Telephone(408)777-3228
OC ,DCkT'Alo Fax(408)777-3333
UrG IV Building Department
JOB ADDRESS: 10775 LA RODA DR PERA4rr# 009 0 /0?0?
OWNER'S NAME: EDBROOAE, JAN PHONE# (408)725-0438
GENERAL CONTRACTOR FAST WATER�HEATER CyO�MPAN FAX# 425-814-9516
I am not using any Subcontractors:_ �" �' '�"`" 9/18/08
Signature Date
Please check applicable submniaacWrs and corn Tete the followinginformation:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets&Millwork
Cement Firdshing
Electrical
Excavation
Fencing
Flooring:Carpeting
Linoleum/Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing j
Septic Tank
Street Metal
Sheet Rock
Tile
Owner/Contractor Signature Date