06120068 Iswi
i lleo,L 11` C11- ,
CM10F CUPERTINO
HbIUDING DIVISION-z PERMIT— �f"Q_TOW-INE0, N
M
BUILDING?�DIJ��SS� g i!,�, AFFORDABLE 06120068
t , j WATER HEATERS
M
(1!0 5
OWNER'S NAME: PERMIT ISSUE DATE-'
,,"oBOBi,'HENDRICKSON 24707 'RAN (FERN ANbo"K to!
2006
SANITARY NO, CONTROL No.
7,
(661).259 7131
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
til F❑ Thereby affirm(list I am licensed under provisions of Chapter 9(commencing Job Description
;,n, with Section 70M).fDwi.mu 31o'dr,Boom. it Prof....COC,V my fie..is
IL,e,1.11.10g,11.nduf 1 REPLACE WATER HEATER
as Ll. (o2
contractor 0TV
, Q0.)�fUt
;:a Done
;*N ''"ARRCCHITECTS DECLARATION
leza I understand my plans shall W used.Inilblic mentis
U
:0to Licensed Professional
OWNER-BUILDER DECLARATION
I hereby afro that I am exempt from the Conlractor&'Liccnoc�Law for the'
I C following reason.(Section 7031.5,Business and Professions Code:Any City orcounfy
i 2 re
which notiones a permit to cortanocei,isher,improve dkitolish,or repair any stricture
1500
pricrat its isurtnionec..1s.round.the.pplitino ftusuch pcorkto RIcitti,ro,diousirev,pt $
the,be is licensed intuttmot to the pmi.ielio.Of 0.Cmilonetto',License Law(Charter 9 Sq.Ft. FloorArea Valuation
eta (commencing with Section 701 of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and ft basis for the alleged examption.Any violation or
Section 7031.5 by any applicant for 2 Permit subjects the aPPItCxrL 10 2 Civil pCnxIlY Of Occupancy Type
Out mom than five hundred dollars($5M).
01,as owner of the property,or my employees with wages as their salt compensation, '(7[.. 1`.:1
h,the will da and the suucpn�I,not in,tarried or ort and for:alp(SEE.R)44,Business
and Prole.6i.ris Code:Tb,,C.9uxCorO's License,1.1w does Out appli'lit in owner oft' ------ Inspections-__-_
brQny whobuilelaor improveilbe&6u.and who does such work himself.,through his I I - "' I
own mpIo,ccs�pmAdkd(hat such impoonervems are pin fifirbled OFOffifed for safe If RiNF0Pc/FA7T1GN* I
Y00
however,thetwking o, 'nownsm is sund wth
iin br1'yCxlOr
� gplcl;cm.the
Wilder ng that will have tho burden of proviat he did�;at Wild rV I ———————
rale.).
of
�1 Construct the Project(Sec.70ilA.Business and professions Code:)no Conuactor's U.'
conse,Law does not apply to an owner of propCirty who Wilds or imparovex thereon,and
who contracts for such projects with a contractor(s)licensed pursuant in the Coromxfo,'d
I Y.exempt under Set. B&P C for this
1. Owner. _._ ..-_ -_._ ._ .____Data-- -. ____�._____.____-_--_._..___.—_.___. .—.__.._—_..L_..__..________...___.___,_---
It,lI17EC%7P_NGWORKER'S COMPENSATION DECLARATION
IC:!DING Pt RMIT:NFO
I hereby affirm under penalty of perjury,one or the following ticclaraiiion
i:[_H(7�' 11.W;l;
Is:
1 have and will maintain a Ccolficate ofoorescrit to xCII.issuWFrWmC7Umri,
itnion.laxprovided Imby Section 3700 of the Labor Ccdcj for.doe perfarmancoof.the U-scl ipt;0ii
work for which this permit is issued.llt,orzq id Pruf,s:!jzo,Codc.a:rl toy iteox,Is!
and will iihiftin Wurkcr`j Compensation Insurance,as required by Sectio
i 37M1 have.rihcLamrCde RudW farwoich this 1.11 isilsitad!
_i. My Workers Compensation-
ciursirn-,;77&�
ILlcrl CER31FICATEOFEXEMPTIONFROMWORKERS!_
o,vd N, COMPENSATION INSURANCE
GWN1`,e, I-11 DIL LARATiCIA
I I(This section need not be completed if 1h;permitis onion hundred dollars(SIM)
z or 1.
13VC!1.,n 7(17.." !!jqi.cs-.Al Pn.ws:e11 Co:e A:y ri, r ,,ty
vel ICC N drai i R the _.W�'C"Pf thew mIc'u'l"�'141 blli kpli�;I
. I - —,.,7 Pc�PET *0
inuaraC) rk IC6., miii'o -i. iv. jrA
wa =in Ifly,m,amor an as to become subjiCt
ire te , _,o. 1 11 k,.., .,+�.
NOTICETOAPPLICANT.If cher making this,cehificati or Exempund;,yZilotidd-
lrttum ' ' ""I' 61 1 1 11.11 .
she[]W dicroted vn1ud.
ons or the Labor C de,you Must
rohlwitti inovidorr'or this lemon :C 0 T:.v Ili
0
"old
> '6'wor
L d
31end
Z Up C"
v nor.effort I,
rehitnift.'
—
b
uildng enter the
"i sp
re I' irm against
ho"i nics
W1 Issaid0l,
Z inconsequence o i c grant] f
APPLICANT' AN WILL IT ALL NON PO "bate
is
rwrvlEC?U IS
Lied
SCUM *, nN . - - I --
Signalure'01'Apoicain/Couloicurr Re-roofs- -G/ 11 �.T 1� f,
_--Awa_,X-,
DOW
I fz,-n,:,�.i,HAZARDOUS MATERIALS DISCLOSURE n t I I nType of Roof I.Lro
Will ft applicant or future building Occupant store or Wool
thitutodmorninenid,
au'd.fl.ed'by t1acCupen m.M.'n,c',VO'j todc.Chapoci-9.12.'and theHeafth
Code'Seeflmi 25532(iOlott W i on, ' n .n'arld Solely: 1,r h'u
All roofs shall be inspected poor to any roofing material being installed.
h h If a roof is installed without first obtaining an inspection,I agree to remove
air 4c_i.. tunum nig occupant use equipment orICts.,kV ,�y Le
,II 1ma a sea air cmnmin11 C.&5ikd by the
DisinZ 7' - — r imloy M. all new materials for inspection.
1-cH 0 ycs !, ON, PVF,� _+"I have rcaJ We ha bws team Is rcyulremcnts unJcr Chapin
9 5 Lh C lifte,
of c a I
niaHCxidh&SafC1,CcnC.SccdCm2S 533and 25534,1undkortandthelifftbuildn''9'
-h "' " - -P Ir *pindf,"th' "pant [
does mo'i'�my to L_theist for I cluecd t� the
Were a, oras
h I,at I sivancc Or P.
nj� ,V
C 11 Or I O'etiloar", Signature of Applicant
I in,
Date
1�1"Mi I I All-roo-f'
Ow 0 Diite�- coverings to be Class"B" o er;ic.;
"A"—��i��
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRESS: 3 PERMIT #
OWNER'S NAME: ,e lL V So ftj IPHONE #
GENERAL CONTRACTOR r til w s�1 C.Ari FAX #
I am not using any subcontractors: % 2-1/�/
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 CUPERTINO
!m 6 of 7 PERMIT RECEIPT OPERATOR: amyw
COPY # 3
Sec : Twp: . Rng: Sub: Blk: Lot :
APN 35705040 . 00
DATE ISSUED. . . . . . . : 12/14/2006
RECEIPT # . . . . . . . . . : 37051
REFERENCE ID # 06120068
SITE ADDRESS . . . . . : 10535 MIRA VISTA. AV
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : BOB HENDRICKSON
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
RECEIVED FROM . . . . : AFFORDABLE WATER HT
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
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
CITY OF CUPERTINO
WATER HEATER ��� ��
CITY OF
CUPERTINO PERMIT APPLICATION FORM
APN# �L ]qo
Building Address: U
i f: TGA
Owner's Name: e#:
oh QiN Cl�Sor n - 4 y3
Contractor: Phone: t<Q 1 License#:
ab e o.-re 2cters a5` 23 ) 10,91
Contact: Phone: 1P to I Cupertino Business License#:
cow L,71J OA
Building Permit Info:
Bldg ❑ Elect ❑ Plumb l� Mech ❑
Job Description:
Residential Commercial ❑
pepickee ilo 1ef Sc,r 2 � CCc,ripv� = GGr� k
Cost of Project:
• Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Grou
BPWHEATER Water Heater/Vent BUILDING
PPERMTTFEE Plumbing Peanit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
•