06120037 CITY OF CUPERTINOlz.
'BUILDING DIVISION PERMIT CONTRACTOR INFORMATION '
BUILDING ADDRESS: PLUMB IN TIME INC ' PP3`Mrr"0'06120037
OWNER'S NAME: PERMIT ISSUE DATE
G
SANITARY NO. CONTROL N0
NE: .
(866) 293-3031
ARCHITECT/ENGINEER: BUILDING PERMITINPO
BLDG ELECT PLUMB MECH
0 0 0 0
i00 LICENSED CONTRACTOR'S DECLARATION
m I hereby afford Nal l and licensed under pmvisimu ofChapmr 9(eommctming lob Description
:zo, with Section 7IXm).f Di,bkm 3.fMc Business anittrotSssions Cn .Wdyry ties.is
in lull
r—a she edea �/ REPLACE WATER HEATER
tjE License C Lic.M
Fp Dale - - Conlmbr
I)GICHMECTSDECI.AllATION
5z i 1 undcrsu id my plans shall he used as public mcoNa
yyU
c0th Licmucd ProfusiotW
'ys OWNER-BUILDER DE CL condra N
1 OO hereby alum tial 11. cmmpt from the Canlracmo LAny Law for IM
ZOO o following masa..(Saito 71y3I.5,Business and Pmrusioos Colt:Any city of munry
f$ which requires a permit re rnnswcL alma improve,dcmrobilt ri repair any aroctum
-i< prit he its iensdpumbentonec.also n ms lWvision of oarsuch Comm roil b GMuigned aw(Cha statement.
(commencing it purwam on Me,provision:or oCtnlramr'a Lianufaw(C CMC)to Sq.Ft. Floor Area Valuation
[��
(commencing is aurept Section 7 DO)and th Division s of zRoged Business and Professions laxi
Naa he u esrmpl thuefrom end Inc basis far dm a0egcd uemption Any violaJon of
Section 7031.5 by any applicant for a permit subject the applicant On a civil penalty of 3 hPIR milleer 0 0 Occupancy Type
not mom than five hundred dollars(5500).
1,ss owner of Inc propvry,or my employes with wages ss the'v sale campcva0on,
will do Mework and the structure Is notimmndcd ormRered fonale(Sec.7W,Business
add Prafet otu Coda:The Comemus's License law,dorm ret apply as an ow.of Required Inspections
propertywho Willsmimpmw .e ,andwhodxssuchwohhim forthmughhu
awn employees,provided that such improvement art not intended oroferedi torsade.If.
however,tha Wilding or Impmvemml u old witWn one year o(cempldtion,the owcer
builder will have the Woden of proving Nat he did rum Wild or improve for purpose of
sale.).
❑1,as mance of the propeny,am exclusively contracting with licensed contractors to
consmct the project(Sec.7046,Business and Prolitimim Code:)The Couvacmr's Li.
corm Law does am apply as an ow..er of property who Wilds or improves dcrton.and.
who contract for such project with a commeou(s)licensed pursuant b the Comrator's
License Law.
❑lamesemplunderSee .B&PCfm Numadin
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby atfrm under penalty of perjury one of the following declarations:
I ham and will maintain a Ce+tifsaue ofCement to self-immm for Worker'sCompen-
suction.as provided for by Section 3700 of Ne labor Code.for the performance of the
work for which Nu permit is usaed
❑1 have and will maintain Worker's Compensation Insurance,ss reyuired by Section
J700 til l fNc or Codc,for ihcperformance merr a Me work for which this PC
tea.
M War t Ceompe/w�uo,n.Iwsturmtt.mice and Policy numbs
�f�,, �r�Cr(6&-7A__
(LJJY/�-7A_ x�F�pfPo�liiccy No
I ✓ /vs^-�rJS I' EPEN9A1'i61P173U�RAACE
(imussection need not he canpkmd if dm permit is Imo:huMmd dollars(SIO
or less.)
1 certify that in the perfomonce of the work for which Nis permit is issued,I shall not
employ any ptmn in any member u as as become subject to the Waters Compensation
Laws of California.Data
Applicmt
NOTICE TO APPLICANT:If,afar making this Certificate or Exemption,you should
become uhfat to the Worker's Compensation provisions of We Labor Cade,you most
.J. O forthwith comply wit such provisions orthu permit shall Wce
dmcd revoked.
'z vy CONSTRUCTION LENDING AGENCY
F Ihcmby aRvm theUmrtused(Sectinn7.Cing agenry for the performame of
W > Le wok far ancon Nis permit is issue:(sat.7097,civ,C.)
fA Name
Limfir's AM
O' landeri Address
U
U Q I agree Nat 1 have read Nis city
application and sum No Ina above l ws misting u
building 1 agree It comply with all city and county oNinoaes and sum laws relating to
Q U abovengconswctinn,and h=rtbyeuthopurrs escmativcs of this city to enter span the
Fyabove mentioned property for inspection purposes.
(We):grato save,andcmmfyaMkaD harmalm inan wCityof Cupertinoagainst
fn I-Ciosepjudgmcm to
expenmsent- may in my way acrncagainassid City
t.)z in eansrqucrtcc of Ne gruning of NU lcrmil
'-' A WCA UNDERSTAND WILL COMPLY WITH ALL NON-POI Issued b 6iDate
s0 GULATIONS. y ,9 - e, L
z '�/ Re-roofs `•tet✓
igna m fA plicmUComi-Wlar Dam
HAZARDOUS MATERIALS CLOSURE Type of Roof
ll do applicant of future Wilding me v sore or handk barardous material
u defined by to Cupertino Municipal Code,Chapter 9.13,and he Health and Safety
emle,suction ss3z(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑oa �Np
Will the a fibmtur mwm Wdam Occupant ret If a roof is installed without first obtainingan inspection,I agree to remove
pP g p equipmcett or devices which p
mit h.,orou s air conuminmss as dcfncd by Ne Bay Arta Air Quality Management all new materials for inspection.
Disuie,7
❑Yu Nu
1 have rood the herardous materials requimmanu under Cltapter6.95 of Inc Califor,
in.1-1caltI, afcty Code,Sa=25505.25533and25534.1urumromd ifav Wilding
dna t cu ndy h4m a tenant,N u my rtspomihility b dsc acupmt of
me tiwhichm me ter issuanaa of Signature of Applicant Date
D ndr mmodrtdas=rat Dam All roof coverings to be Class "B" or better
CITY OF CUPERTINO
1 of 2 PERMIT RECEIPT OPERATOR: bethe
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35622018.00
DATE ISSUED. . . . . . . : 12/11/2006
RECEIPT #. . . . . . . . . : 37001
REFERENCE ID # . . . : 06120037
SITE ADDRESS . . . . . : 21681 LINDY LA
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : GABRIELSON DOUGLAS B AND LINDA
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4807
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
SE 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
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
46UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
'70) d - Lc
OWNER'S NAME: u2. re-s, I PHONE #-q-
GENERAL
GENERAL CONTRACTOR: FAX # 7
I am not using any subcontractors:
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
Tile
•
Owner/Contractor Signature Date
CITY OF CUPERZTIP�o
,Ct,4 r-ER "EATER
WA
APN
3 ,
13
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BU °?ng Address: � Bate:
t 1681
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Owne s N 6
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Conir4ctor _ Phone :
9O�'
Con[—a,"t- — Tis License#:
i Building
ermit info:a Cupertino Business
I License n:
? Bldg !ED
Elect /
Job Description: - �/- Plurnb
f' Mech jY
j Residential
1 ! Commercial Cj Sfl ;
Cost O f Project,
Strapped ' 1
On Platform
Bonded
New liocation 0 I
— Replacement
Qty-1 if
A, licable Fee ID
"WHEATER Fee Descri
I PPERMITFEE Water Heater piton F
' ,' BENZ=AGY vent Fee Group
P-urrbinfl pe BUILG
DIN
BUSI,iC Erer�y rmit issuance
Business License PLUMING
BUILDING
BUILDING
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