06050014 CITYAF'CUPERTINO ^pa :°�
BUILDING DIVISION PERMIT C'�1AITItA' "I IIVI QItMe�T D
"OW'4s �rs` '�x ,lea& ...
BUILDING ADDRESS: AFFORDABLE WATER HEATERS PERMrr NO.06050014
19625 MERRITT DR
ER'S NAME: PERMRm" DATE
CHANG, SUE 24707 SAN FERN
P NE: SANITARY NO. CONTROL NO.
(661) 259-7131
ARCHTECTfENGINEEW - BUILDING PERMIT MOO
BLDG ELECT PLUMB MECH
f = =
I�'d LICENSED CONTRACTOR'S DECLARATION Job ()
i 1 hereby affirm Net I w Ikmm,d under PmvWana m(CMpter 9(¢mmmcin{
Secdon70(I;jfc, iHaion3of Na BusimvAM Proluaians Cade.and mY licettsota
a.Nm Li.lifaam�mke,tuar,)lgt._ 1 REPLACE WATER HEATER
D.n S-f-I,h Ganosonr JUN 2006
I I und=nunJ my plena shell,he usual uARCHMECC E1,1AT.,N MOM fary�� pps�
and Liceresed PmfessionaI OWNER-BUILDER DECLARATION
����(I II��\\n�
1 hereby aalm that I I.S.exempt from the Conlns Co :Any c Lew for the w,l
RX o following moon.(Satiate 703 1. Business and Pmfeuiuns Cade:Any city or county
5$ which mqulru a perm,to commucL slkr.ImpinK,demoltaaoh,car m,mr any mmo $800
-It^^ prior to iu issueme.Also requires the applicant for such permit On ilk a signed stamancM
E C
that heis licensed pamentmthe provisions ofthe Contractor's li¢m=Law(Chapw9 Sq.Ft.Floor Area Valuation
e�
(commemdng with Section TEAM of Division 7o(Ihe Buslrcnand Prefcuiona Code)or
8 that he ls exempt therefrom and the basis for,the Alleged mempdon My v1olWon of
S¢don 703 LS by Any,applicant fm•permit wbkcu de,Applicant to a civil penalty of JAW Iftifti, U U Occupancy Type
Ann mom than BK hundred dollars(SSW).
1,u owner of IN pmpmty,a my wployeas withsolea u thele sole eampensedon,
wiadothework.md Neavunumism,intendedara@ndforuk(SM.70as,Busimd Inspections
Required
and PrnkStlem Cade:The Conuaetefs Liemm "s Law dml Apply m Ad ower of q
property soba builds a ire proves thmmn.and who does such work himself.through his
own emplayrd,provided Nstsuch ImpmKrtwm art ml inwded aroRemd fasale H,
however.the building"Improvement is sold within am year of compkdm.the awful.
builder will have the burden of proving that he did m,build or improve for purpose of
Asia.).
❑1.As awmr of the property,iso exclusively cmusning with If¢nsed¢ntrotan to
consotm the pmjen(Sac.7644.Bush.And Professlom Code:)The CmuAa&s Ll-
came law dors ant apply n An owner a(pmpeny who builds or Improves thereon.red.
who concocts far such prejeeu with amnlncnRA)licensed Pursuant n the Canmct-e-
Liceme law.
❑I om oempt under See .B It P C for Nis moon
se Dau
WORKERS COMPENSATION DECLARATION
I hereby Alam under penalty of perjury,role of the olowing declammuc
❑I ham and will maintain a Cenificam o(Catoenl ntelf-inmrtfaworker'sCompen-
within.u pmvlded for by Secdon 3700 of tha labor Code.far the wrfoman¢of the
work for which this permit is issued.
1 have And will maintain WaMts Compensation Iruuran¢,As ru uired by Section
3700 a(the labor Code,("On,per(armmce a(Ne wmrk for which this permit is issued.
My Warke's.CCounia made Insurance carrier and Policy murder art:
Carrier. / h.P- Prv�l`l-L Pa11ry No.: /0r� &CIg7O (
CERTI4_ OPEXEMPTION FROM WORKERS
COMPENSATION INSURANCE s
This aecOm load ret becomplemd I(the Permit IS forms,hundred donate 03011
car leu.)
I cenify that in the performance of the work for which this permit Is leaned.I shall not
employ any person in any manmrm as in become subject to cite Wor turf ComPAAAl
Laws of Cai IONOI .Data
Appaan,
NOTICE TO APPLICANT:If,after making NB CeniOcam of Facropol you should
became subject in the Worimes Compeasadam provisions of the labor Cade,you muss
wJ O forthwith comply with each Provisions or this permit shall be decreed mated.
z w~N. CONSTRUCTION LENDING AGENCY
(-t I hereby from that then I.A eowutdm lending wavy for the Parr--of
lYi> the work for which Nis pend is issued(Ser.3097,Civ,C.)
WM Q Lender's Name
a7 z lender's Address
U I coldly that I have mad No applkadon and sun that the above infomadan 6
corms.,'pee to comply with all Ally and county ordinances,AM mu Iews mlaung n
O building construction,and hemby amNrme mpomminum of this city m Amur upon ft
E
W above-mcmu cd pmpcny f"Inspection purpose{
L>. (Wer)agree of now.Indemnify W keep homeless do City of Cupertino agonal
,.y y IlaMlides,judgmenu,coal,and expenus which may In my way acnue againsuaid City
(')7 m eomegmntt of On from as of 's permit.
F7 APPLICANT UNDERSTANDS NO ILL COMPLY WITH ALL NON-POINT Issued by:9102� Date , r
SOURCE REGULATIONS.
S- 1-b 1, Re-roofs
siglwureaf ApplianUCon r Due
lType of Roof
NA7.AR US MATERIALS DISCLOSURE
Will the applicant or future building acapantnom orhutdle hsvamous material
a de0ned by Un Cupenino Municipal Code,Chapter 9.12.And the Health and Safety
uc.seedzs53z')7
❑Yes _ / All roofs shall be inspected prior to any roofing material being installed.
en �1FO
WIII the spPlicanl or(mart building aecupanl uso equipment"devi¢a Mich If a roof is installed without first obtaining an inspection,I agree to remove
'"'I hayardnm air conuminanu u nmd by the Bay Area Air Quality Manag=mcnl all new materials for inspection.
District?
❑Yca Ef4N
i
I haw mad the buatdoue materials requiremcw unds rchapw 6.95 of the b0ifm-
nuHcolNASalmyCade,Sxtiau25 3,23577 and 27370.1 undemaM thn ifdm htilding
data Out currently heK A 1 N it is my maPomihilily n miry Ne occupant of Ne
requirements which must W nwp rniou ¢oOccldncanaf Oc¢pmwy. Signature of Applicant Date
veS- Dan All roof coverings to be Class"B"or better
own"aeaNa d.e=tel
CITY OF CUPERTINO
I� 6 of 6 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 31635001.00
DATE ISSUED. . . . . . . : 05/01/2006
RECEIPT #. . . . . . . . . : 34203
REFERENCE ID # . . . : 06050014
SITE ADDRESS . . . . . : 19625 MERRITT DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . :
OWNER . . . . . . . . . . . . : CHANG, SUE
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-2437
RECEIVED FROM . . . . : AFFORDABLE WATER HTR
CONTRACTOR . . . . . . . : LEONCE ROUX LIC # 26850
COMPANY . . . . . . . . . . : AFFORDABLE WATER HEATERS &
ADDRESS . . . . . . . . . . : 24707 SAN FERNANDO RD
CITY/STATE/ZIP . . . : NEWHALL, CA 91321
TELEPHONE . . . . . . . . : (661)259-7131 -
•
FEE 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
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ------------ -----_----_----___
OTHER 504.12 MASTERCARD
TOTAL RECEIPT 504.12
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
CI OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS: PERMIT# OzDf
I�lbaS Mem-IT P!
OWNER'S NAME: PHONE # 4oy_ j Sa-
GENERAL CONTRACTOR FAX #
I am not using any subcontractors: .li s 1-,Ob
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
S-/-Ol
der/Contractor Signature Date
CITY OF CUPERTINO
WATER HEATER
*CUPERTINO PERMIT APPLICATION FORM pbD5oolg
APN# Date:
3/(v 35.001 1 S ^i o 6
Building Address:
IctbaS MerriTf I�f.
Owner's Name: Phone#:
See ChAn yok- " Sa S33S
Contractor: Phone: colt 1 License#:
ab 0- UL71e mre.rs 9S� -713 I toad 31.
Contact: Phone: &61 Cupertino Business License#:
co'lT Li-TI I chP.td 5 o5au a �gSo
Building Permit Info:
Bldg ❑ Elect Plumb d Mech C3
Job Description:
ReQIGc� ' lu ajlo\ WoXer Huller CSQrne joCar�Dn
Residential Commercial ❑
Cost of Project: (JDa
Strapped On Platform D Bonded
New Location ElReplacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMTfFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
•