06090158 CITY OF CUPERTINO `�'
Buamnc'mvlsloN PERMIT iCONTRAC�(fRINFUILMATIO
BUILDING ADDRESS: ALL VALLEY PLUMBING PERMITNO.06090158
22059 MC CLELLAN RD
OWNER'S NAME: PERMIT ISBUE DATB
PAM WARREN 3345 SELDON CT 09/20/2006
NE: SANITARY NO. CONTROL N0.
(510) 376-4816
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
' BLDG ELECT PLUMB MECH
job LICENSED CONTRACTOR'S DECLARATION JOUD0SCf1 Description
l t`IF 1 hereby afOrm that 1 sm Warned under provision of Chapter 9(commencing p
with Section 7000)of Division 3 of the Business and Pprofession Code,and my lkcoeb WATER HEATER REPLACEMENT
infullforctand —794 39D
>'('? Lkenm las 1 I O l
Date Conuumr
ARCHITECTS DECLARATION
l I understand my rims shall M used u public accords
!sea Licensed Professional
OWNER-BUILDER DECLARATION
Z I hereby affirm that I am exempt from the Cuntnmars Lieenu Law for the
OO following mason.(Section 70313,Business and Profusion Code:My city or=my
I$lx which m ulna a permit to emsnum,alter,improve,demolish.or repair any structure $482
-ms
prior mits issuanco,also rcquiw the applicant formchpermit W fit uiged statementValuation
that he Is licensed pusecmt to the provision of the ConuxcWra License Law(Chapta9 Sq.Ft.Floor Area
$ (commencing with Section 7000)of Division 3 mane Bummmd Professions Code)or
— that hen,cumin,therefrom and the bub for the alleged!ruenpUdo My violation of
Section 7031.5 by any applicant far a permit subjects the applicant we civil penalty of 3xP9M69rUU Occupancy Type
an,mom than five hundred dollars(3500).
❑I,uownerof UepmpenynmymploymwithmguuUe wlemm dm,
will do thework,and the suurure is reprimanded or offered forsak(Sac.7044,Basi. Required ections
and Pmfudnn Code:Thr Comra mrs Lk.Law dam not apply W an awnr of q p
property who Wild,or i m prow thereon,and who does such wart himself ter through his
own employee.provided that such improvements ace act amended oraRerad(resale a. L�
howaw.Ne Wilding orImprovement Issold within oeyear of completion,tle owe r-
builder will have t!ti burden of proving that k tlld trot stilt or improve far purpose of L v
ask.).
1.as ower of the pec.704 am names and
contProic sdoes withCod lianed moscuseu e O
ca La the es not apply
t an mmoBusr of and R,who n ds or
Them thenen, sad
cense Law case not apply to an owner of progeny,who sp es improve Chante and
who contracts farasch gajecu with a mnuanmp)licensed puasnn,W the CantaaWrs
Lice=law.
❑Tom uempt undo Ste .Bk PC for this tenon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty at perjury one of the following declaration:
I haw and will maintain•Cer iOnte of C...I to self-insure for Workers Camper-
sodium.an provided fur by Section 3700 of the Lather Code.for me Performance of On
work for which this permit is instead.
❑1 have and will maintain Workers Compensation Insurance.u re uired by Section
37013 of On Labs Code,par me peNoa ease of On work far which this permit 111 based.
My Workers Compensation Inmmnce cemi,r and Policy number are:
Cann:MA: �hill ITN- Polity No.: �B s�}�OI
CER71FICATEEOFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not Is,completed If the permin Is foranc hummed doltan(SIM)
ter icon)
I certify Out In the performance of the wad for which this permh Is iced.I shall not
employ any parent in my Manor an u W became subject W me Waken'Contpenation
Laws or California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Cerill of Exemption,you mould
became subject W the Worker's Compensation provisions of the Labor Cede,you cater
,J O forthwith comply with meh provision m ON permit shall be tarevalued.medrevalued.? CONSTRUCTION LENDING AGENCY
[r I hereby grim that inert its cmuVuction ending agency for the perromane of
f�
On wd(or which tan permit Is Issued(Sec.3097,Civ.C.)
W Q Lenders Name
z Lenders Addmu
U Q I unify that I have read this application and sue mat me above information is
V, H conect.I tgme W comply with all city and county ordinances and suns laws relating to
OV building construction,and hereby authariueprcunutives ofmis city to enter upon tie
W aMvomemiuned progeny for insrecuon purposes.
(We)agree 10 save,indemnify and kap harmless Or City of Cupertinoagain.
tF—t ,n Iiabilitieajudgmmts.costs mdex,maces which may in my way acne gaint saidCity
V 2 in consequence of the gem ing of this permit. ) /
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURq REGULATION .
zre,ofM,� 9/�✓UG Re-roofs
Signature of AppliceHAZA rcoar Dee
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII On applicantor(uuni buildingoecupantr9.1 ,handle haralm nmatesia
as defined by Ute Cupertino Municipal Code,Chapter 9.11,roti the Health and Safety '
Cede.Session 25531(4)7 All roofs shall be inspected prior to any roofing material being installed.
❑YonQCu
Win me applicant o utuac building occupant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
emit huardous air contaminmu u dented by On Be,Arta Air Quality Management all new materials for inspection.
Dimic,7
❑Yet on
1 have mad the Mandous materials requirements under Chapter 6.95 of the Califor.
nia Haim At Sa(etyCede,Section 25505,25533 and 25534.I understood mu lithe!Wilding
Joos but currently ban a tenant,that It u my rcspanibility W notify the occupant of the
rein .nos hich ran= et r W iswmce of a Cartilage,ofOccupowy. Signature of Applicant Date
Owner x<d.g—S '—�'&I 3f l o" All roof coverings to be Class"B"or better
CITY OF CUPERTINO
!m 1 of 2 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35713024 . 00
DATE ISSUED. . . . . . . : 09/20/2006
RECEIPT # . . . . . . . . . : 36129
REFERENCE ID # . . . : 06090158
SITE ADDRESS . . . . . : 22059 MC CLELLAN RD
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : PAM WARREN
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : ALL VALLEY PLUMBING
CONTRACTOR . . . . . . . : MARY SANDBRINK LIC # 23015
COMPANY . . . . . . . . . . : ALL VALLEY PLUMBING
ADDRESS . . . . . . . . . . : 3345 SELDON CT
CITY/STATE/ZIP . . . : FREMONT, CA 94539
TELEPHONE . . . . . . . . : (510) 376-4816
EE 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
'OCIF Fax(408)777-3333
`UPERTINO
Building Department
JOB ADDRESS: PERMIT #
g �
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractor
Signature Date
Please check applicable subcontra rs 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 CUPERTINO OoOga�
WATER HEATER
C TY
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building dd reds:
Owner's Na ^ Ph
Conct �r: A</ 177�/ v• / //'�D License#:
�o�o
Contact: one Cupertino Busines License#:
i? ��.� mid 6�/=fo9� o�
Building Permit Into: /
Bldg ❑ Elect [ � Plumb UY Mech L7�
Job Description: GLS
Zoe
Residential Commercial ❑
Cost of Project: `W 57—
Strapped On Platform LJ Bonded
New Location ❑ Replacement
Qty. if
A licable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPEFlvff EE Plumbin Permit Issuance PLUMBING
B Ener BUILDING
BUSLIC LIC Business License BUILDING