00110023 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILUING ADDRESS: PERMIT NO,
22685 MEDINA CT WATER HEATERS ONLY 00110023
OWNER'S NAME: APPLICATION SUE GATT.
AM RENDER CHIU 500 AIRPORT BI_V 11/03/2000
91ONE; SANITARY NO. CON I ROL NO.
(415)349-3747
CCL ARC[UI ECIENGINTER
BUILDING I'IiHM'r INTO
a,O O BLDG ELECT PLUMB MESH
S N= I.ICCNSI?U CON1'HACIOWS DECLARATION Job Description
f2mp Iherebyatlirm Ihm
<yc; Sccooe0apoDv 1nanmSotthe 1J3
uunmdeevr-aennddoPmfnososifo-C nIq 9a,dmseyn lactose
is inn""r"°"``" n
cone
REPLACE 40 GAL GAS WATER HEATER
On U License Class Lic,a
3 Use Comeanor
-a.0 un ARCIIn'Ecr'S DECLARATION
1 lcotand my plans shelf be used a,public rereads
50. i
W p C Lican.wJ Prolcssianu
W
OWNER-BUILDER DECLARATION= ece I heaby.pithat exempt
1 am exempt frr om the C,,iop, o License law for the
falloa, whichingninesa Section 7031.9,Pothe,im,ro'mfeuiom Coyle:Any city fir enure
`Fp whir,,i:,,m:lIverinit,ulkom,omorms,tl,,;;tiler,imprnw,dam ml ,fir repos any 'nenrcal
patlieslcense pursuing
the fhovisioso ser Curmmmeinoiceew aw(Chpter9
al
'hat lie is licensed writSectionnmeprnviiinn,non<•emttmetn..LiadI'm�wlnsCor9 Sy. Ft. Floor Area Valuation
(coan t he is exempt with Section]WIO of Division l of the Business send P rt.An li Gde)
or Ihm he i,31.5btherefmm and the basis for the alleged exemption.Any violation $700
of Seminn](131.5iv any applicant tor npermit suhjcert the applicant nnacivil penalty
mmol n)uee man hoe l...urged donars,$s«n. APN Number - Occupancy Type
❑Lits owner of the reopened or any employee,with wage,us their sale enlnpensm 1 3421.9 Q} 00
will do the work,and the ztmaurt is not intended or offered for sale(Sea.TW,
Business and Pmfa.,im,cads:The Cnntr mm's License Ww d:se,not apply m,an Required Inspections
,, r of propcny Who builds or improve,Ih boom,and aha does such week himself
,giongh hi,.n,vn emp4w,c,.provided that suchimpnwentnnl,are ran intended or 502 — FINAL PLUMBING ENERGY
offered fir vale.11,however.the Mudding or Improvement i,sold within otic year of
omplmion,the owncrbnilder will have the burden of proving shat he did not build or 506 — GAS TEST
improve for pa"a""'f x1° 507 — FINAL PLUMBING
❑1,;1%owner of the propene,am exclusively contracting with licensed commons,to
....tmm
n,the n oico ISee.VIUq,Hmcas ami Nufcsvnn,C:xlco'If.Cum ebor, ,
License Law docs sol apply to set interior po,s ro,who builds or hnpnrvcs Them i, .
and who contracts for such projects with a a,nvacmgsl licensed pursuant to the
Cnn,rucars Lieenx Lm'.
❑1 am exempt under Sec. .B h P C for this reason
Ower Uwe
WORK17R'S COMPENSATION DECLARATION
1 bereby algins under penalty of perjury one of the following declamtinne
I hive cued will a mien a Ce tificwa of Consent nn,ell-home for Worker',
10 ompen,atlnn, a, provided fnr by Section 3701) of the Lubar Code, lar the
performance of the work fin which this permit i,issued.
❑1 have and Is maintain Worker:Compensation Inwnaac,as mr,iml by Section
37M of the Labor Code,for the pcd'nrman<e of the work fnr which this permit i,
sued.My Workers Compcn,arber Ildurnnce Cartier and Policy number am:
Cunicr: Police Na,:
CEKII FICA r1ON OI'EX EMITION FROM WORKERS'
COMPENSAIION INSURANCE
Cutis xenon need nut be completed it(lie permit is Ise one hundred dollars
fb hall or Icy,.)
I certify that in the contaminate,of the work I'nr which this permit is issued,I '
shall not employ any evar in any announce.as ,,become abject to the Workers'
Comp usation Lux, it California Dan,
Appl'eant
NO I'eCE TO APPLICAN'L If, it,,making this Cenilieutc el Iixnnplion,you should
enuu
e subject the Workers Con,pemalion provisions of the Labor Ced
Code.you trust
Z r
C hm
fnnhwi,h comply with sucM1 provisions m this pcnnil>hall be deemed smoked.
(~ ` CONS'em is a c N LENDING AGENCY
a ' healthy shine that there iss csued(Sic. lending agency for the per&mneme
Lethe work for which Ibis-conn s issued(Sec.70N97.Co,C.)
6. Q Lender's Name
= 7. Lender's Address .
U C I certify that I have read this application and sins that the above information i,
h F um¢t.1 agree it,comply with all city and county..dioceses and supe laws relating
O V u,building cnmtmction,and hereby nounrimmpresentaiveufflux city I,mnmr upon
Ihu above-mentioned proper}bar in,peni er purposes.
Give)agree it, indenmily and keep bnnlcn the City of Cupcnino against
h liabilities,judgment,casts and expenses which may in any way re ms against said
V z City in consequence ethic granting if(his proal.
SOUBCANT ON DERONSNDS A NO WI LL COM I'LY WITII ALL NON-EVHN'I' Issued by: Date
Signature ofnppheantlemtri Date - Re-roofs
HAZARDOUS MKITRIA1 S DISCLOSURE
Will the appfieaot or mare briding eceepmn xlore or handle ha,adou,nenerial Type of Roof
an droned by the Cilia,nla,,MI Cod,Chapmr 4)12,and fire Hadth and Safety
Code,Section 255320)';
D Ye, C1No All roofs shall be inspected prior to any roofing material being installed.
wiuthe applicant orfuture building occupant use equq,memordevices whieh If a roof is installed without first obtaining an inspection, I agree to remove
tit h;vadom amnt
sir continas a,def iecd by,be B.,Amo Air Quid Managcmm�t
ui,ldelr all new materials for inspection. Applicant understands and will comply with
°Yes 0 N all non-point source regulations.
I have read the hamrdnus materials requirements under Chapter 695 of the
[Cal dentin Health&Safely Cod,Seainm 35505,25533 and 255...1 understand that
he hui ding Jots nm nmcm ly havea mar.that h in my responnihllny to polity the
dupuu ol'tile mquirm u.'ns which must be mm rir m ixsumme of a Cenilicwc of
cupancy. Signature ofApplicant Date
ner metho tied aern, Date All roof coverings to be Class"B" or better
OFFICE
—�
NOV. 1.2000 4:40PM NETCLERK INC N0.985 P.1
TO:EPERMITS
720 Dubuque que Ave., South San Francisco, Ca. 94080
rermlt
� r• • fItEily l I Government Services: 888-330-1777 Application
XIS ;�r ��r!iJ ,I' �.4 jliiijr' i1'' ' 1 ;'� ;M1; , ,iea:,iUm7 Fax: 877-846-5888
Email
To:Cupertino Permit Handling Instructions
Building Mail
City Hall 10300 Torre Ave The city will mail the approved permit to contractor.
Cupertino
CA 95014
4087773333
Contractor Information
Company:WATER HEATERS ONLY, INC. Worker's Comp Carrier: STATE FUND
Address: 970 E. MAIN ST.#200 Worker's Comp: 1516265 Exp. 04/2012001
City: GRASS VALLEY State Contractor's Llcense:374573 Exp. 05/31/2001
State I ZIP: CA 95945 Fxp-
• Phone: 5302743001203 Exp.
Fax: Business License #: Exp.
Email: H2OHTRONLYQAOL.COM
Credit Card Information
Credit Card Number: 4678037179990 visa: 0
Expiration Date: 1 / 2001 Mastercard: 71
Card Holder Name:John P McGee Other.
Notes
Pre-rag: YES Attachments:
Payment:VISA WCQ SCLQ SASE 2] AAR]
Agent Authorization:YES Permit Type:
ORG❑ NOTE] FV-11 Permit ID: 64180
Project Address:22685 MEDINA COURT
Comments:
NOV. 1.2000 4:41PM NETCLERK INC NO.985 P.2
' C><TY or cur) RT7N0 CONTRACTOR
nTTa.niNc nmsiPDy 1tNIlfORM(ATCON:
BUII]]OVG ADD7RFSSI PliR2.RT NOt
22685 MEDINA COURT WATER HEATERS ONLY, INC.
• ONNPA'S NAMP APPISCA ON SUE)PATE:
G RENDER CHILI970 E. MAIN ST.#200
PHONL:: SANITA YNO. CONTROL NO.
g 408/873-4142 GRASS VALLEY 95945
2 q AONiTL'Ci/HJODIEE0.• BUMMING PP INFO.
5 5302743001203 �"Fj
C�
u ftL I I licensed und'rDExLIRniI01V
C 1 hereby mOf Rm1 1 em licensed l ttdm or io CC04 9 (mmmemeg lobDueliplion
Ola salon 7000) of Diuietm T or pn awinen soul Prokwbm code, ed ray Ikmw REPLACE 40 GAL GAS WATER HEATER
ie evfun[vino Oa.
� Licevae Pans�9� l;a a 374573
a
11/01/2000
Dux: Coatnm
a
yyy�D .Do.," ,'411c v.CLick,
a6m �yDmaf FNll tle nFMropuelle rcwMa
k� d
. I .. UILDSRo. fig,MTION
❑ f hereby etlinm Ihvt I em mmol Gum the Coo®°Ire's U.Any city
fm the sq.P•t.T•Ioor A[ea VJrn61100
% Idbwtoe Rwon ldmdon MIA & at ab ProRuiotu Looe. Any ea a may 700.0
:i
pride
tad Ig a opines m nmsnot dW irII, si diol. ,vas wv ew,tw
Ma m In awns, step R9oheu dee Madge M rvaA penal if (ilkO a 9(f wmlan APN Num er r I Occupancy Type
,tit helh'cmdpmwvndm pmriu®KSedImir fa Lxrmw L,w(OO4 agwommem'vY
a and he b9 for Oce 01.1dca J stAe Bwhnw cud o.of S Con)a dem he o,nmpt nt for g
and the bvh for tM ales, mvnplbn At y f Not11 of demon 7OTI5 by any 1JOTJ rat ran e
p�nh n-eJca me.pPika,[m a dull I,eWa of not wine Iban Ilve hundred dol lora(4500).
LJ M u arum e[Po wwmty,w m mMo>am with wya m Il,o'v cele eompcmltiop win do R"ifed[nepmtiON
w Dark,ad duo unuting u am haem'd Or oebud for sole(Sea 7044,Ddims and Pmitn6u
Cad,:The Cee rnwor,IYrele b does we gply of 01 oWae ageopery Oso bales or hol mw
!1s.soul Who it. mels Wink haeelf for brud m own employers v ied 0m ouch
udpaem®e w itmdd winedtr mea It boema.the bmldmd Or i en.Is sold wiOu
one hen,or eomlifo ,do o„wmyoaog,wit sore din bomet of prows Ntc be dd,w1 bww
or imp,"Ido pnpme of sole.).
❑
I, is owner of propery, an mclwirat' nonnxunp With lineeuvd m... to
conutuot the project (Sen mid, Dwinem ad profusion Code:) Tba Dormse ir's
U"ON: Lew doll not apply to on Tuan of aaMny Olin bulla Or impm:e under,
ed who ron®cm for unto Mines with a comma(') licami P.. 1. Re
Nmrmm,'u Gang Lw
0 I w userw o dan dao. .B S I'C fm thY ream
OwnvDim
WORKER'S COOIPENSATION DECWIIATION
• t htreby omni undorenthy of lfujury nee of the fbll°wi'dedvnetiam:
❑ 1 here and Will maintain a C Mcgglc of Credal to aav-idtu, for walker
Cne,pnudoR m pmddad for by Section 37w of dee Ub°r Coda fer da
12rmaga oftse Wank[a wbieh this p,mall Is iu wu
i low and wD mwoa wbda'a Diminution omnae m revived by &,tion
37.0 of the L , Cdr, to, the pvfammm of db Oak hr which ,his pwenit is
iwod.My woeka'f Compeaemlaa Dsimiwe sada mid Polky number me:
c, ,O,STATE FUND pa"N.1516265
CIRTIFI9AT1ON Of"IMPTION MON(WORKDA.y'
COMPENSATION RtSDRAIOa
(This septi®need nes M compound a the Pert a nor one bin td dvnm(EIOO)Or less.)
I adlfy Wo,le be wt's m but or the nark Ibe whkh ,hb parols Is owed,I
shell not mp]W any ,crane in un, memim sO as in beeesne "got be Ibe Warkers
C rdp,mpllal Lt.drWimilF. �/,,�,,yy,,���
X11/0112000 ANlies _U2A `f-_
NOTIM N APP.ICAN1': It eRm making this Cmdaeom Of Ibadishoc, you should
Dema mom on Ne WmM"I Canpdvsmlm pm ddmu Or the Isom O'k yin mm
thdowith amply cull wh pmvmians Or this pvmtil shall bra dermed revoked.
CONFTRUCTION LENDING ACENOY
0 I hereby sQivn thin thin is a eeeseen.e beam0 02 acy for IM pmronvin
nolle wink Rr cults this Pwnh u imued(Moa 3M.Civ.C.)
a
Lepdv4 Name
o uadm'1 AOORw
YD! 1 adirr the,I holo need led notimiOn and nue Nu Ne Mese htleflego n a
O5 arra, I Spm m soul* rid, W db sad energy, ml®r Now amu Isw nNtinO
n bddmS cwmducdod, and hath, echend repmmt®•a a oris nit, In ,smr gone
On iDOK-niMNoitd pmDem for inspection one aew•
(We)Senn NO w o,mentally and keep hSenelen 1M City of Comilre, num,
liabilities, judgnxns, . and Wartfe Ohms may ie Oce, ray amus apuind pod
City m cneeada0w oClim Onanlina vials peMiL
nPPUCANT M^^^^'`^"•`T)WILL IpsO'LY WRN ALL NON'POMI'SOURCE
REOUI-APONS_Yak"_
11/0112000 RFmofa
digtmnevrnppaam/Gntmmr DnO 'TypeofRtwf
F1A2ARnOVSMATRRMACSDISCLOSDAE
Will too finlimnt Of ToWn building oeaant pan or handle hamtdow wmdol A4,root$sball be inspected prier to my roofing mamrlal being inamlled.
as de0nd by the Cumung Mudaical Cott, Chn or IIA2. and em Nakh And 31wIEa roof id iMWi6d with0111 Bret ebWning m inepeclion,I agree O remove
Code.Scmirn 24J33(p)1 tte❑ No
all ttuw mamriala for iaepectlon.Appllam nidmundp and will comply with
will the "Plitud of (neva b ill Occupant we quipmm Or devices WNsh all denmeint farce regularlma.
anis ognown, dr ammvkoeu eAtOa by Ray Ara nu Qudi, Mm.hvmmt
DismO Yw No� 11/01/2000
I have need Ow Mm a mneriab mlvimndeu Onde, Ch"Isf 694 of dm
• Chemie I[Wth 8: SOD, cad, Sodom )"" 2,5n sd 21o3e, ] uvdmtmJ son
if dee buil!:- haw a mum Lim 'I u my mpctuibiliy to ramify the Signunre of APPlimn[ Dale
x... ..,, ......L, t
ottupaa o� h ami he son peso m tsstmme er n C insole of ARroorwrmin)g to be Cltee"B"arbeacr
O'ne°enn' 11/0112000
Ovmero•augodDd arm Date OFFICE .