06060229CITY OF CUPERTINO
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LUILDINGti1VIS1ON PET
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BUILDING ADDRESS:
PLUMB IN TIME INC
PERMIT NO 06060229
11204 MT CREST DR
--
09NAME:
PERMIT ISSUE DATE
KNIRCK DOUGLAS
360 MEMORIL�L DR STE 140
IV NE:
SANITARY NO. CONTROL NO.
(866)293-3031
ARCHITECT/ENGINEER:
BUILDING PERM" INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
P
1 lmmby affirm Jul 1 am licensed mesa provisions of Chapter 9 (commencing
with Section 7ofh0 fDivislon3ofthe Businev ( oro and dosis
infullro ane
HOT WATER HEATER 50 GAL GAS
Licerue Lie N
-tREPLACE
Dam Cones
ACTSD N
I understand my planss"ahJI hIse used as public arts
Licensed Professim it
OWNER-BUILDER DECLARATION
1 mmby afrttm that 1 am saempl from the Conuanoes License law far the
following mason. (Section 703 1.5, Business and Profusion, Cade: Any city of county
- $500
which mquims a parent n to announce, slur. improve, demolish. Or repair any mmemre
prior as, its issuance, also requires me applicant for such permit a rile a signed suumes,
License Law(Chapter 9
Sq. Ft., Floor Area
Valuation
Ism he is licased Nassaua the provisions efine Conancu's
(commencing with Section 7000) of Division 3.fam B.shun sand Pmriesumm Code) or
that M is asempt Umtefrmn and the bub for am idtal exemption. My violation of
.3 ?&jqW&*jI5erU U
Occupancy Type
Section 7031.3 by a" applicant for a permit subjects the Apidiant m a civil penalty of
nal mom than five hundred dallata ($.500).
0 I,Uo ofN pmpmy.armyemploymwithwgesudiekwlc=m=Uon.
Required Inspections
sa toad,mans,
wachnmNLiense,
ands:
Uaue law don sol apply lf rt own, of
and professionsCode: The trsem Lawdoes
and The apply
q P
is
property wh lou we and who work himselfar reminds his
propertywho buildsarimprovesch ,
quitsuchImprovementssac not lean ofcded mlildia.istreired fm ole R,
improvements ammo in
manhoweemploy=. thewlthinamyear theow: ur-
Wilding
es,
builder illbandindarimpmmroentbaeu
w improve of
builder will loam me burden of proving Uel Ise did nm build m improve fa purposes: of
uleJ.
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❑ 1, as awm, of the property. am "elusively convening with licensed conusnms u
PRj/jlyt'y�lAFf
couuun the project (Sec. 7044, Bustin and limitations Cade:) The Contraclafs Li-
cove law does net apply an an owner of property who builds or improves dune n. and.
who contracts fm such projects wish a cermicu (s) lkrmed pussuam m We Conuacur's
Q 24 8
01 J Lti
Limens Law.
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owner Data
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WORKER'S COMPENSATION DECLARATION
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1 hereby affirm under penalty of perjury maturate fallowing decluWau:
Lr�`�f
1 ham and will mmnuin • Certificate afCoass nt to sel6buurt fm WarkehCampen-
sadon, as provided fm by Section 3700 of the Labor Code, far the Patfmmulce of me
work for which this permit is !=and.
❑ 1 have and will maintain Work es Compensation Insurance, as acquired by Section
3700 of the labor Code, for the performance of the work fmwhich this pesmhis Issued.
r Y pe saronl and Nirynu vase �
e/}(Ca� s..0 F FfEMPIIONFROM WORKERS
r 4s�� [M SATION INSURANCE
(This seeUon need ulbecomPlemd If the palmin is furonmhundual doBam ($100)
or leas.)
1 certify that in the performance of me waHt for which this permit is Wood, I "I oat
employ any person In my turner W as in became subject in the Wofkera' Gampe atudon
,
Lawa of Califmaia. Dam
Appliam
NOTICE TO APPLICANT: If, after making this Certiffcau of Exemption• you should
became subject be the Warkefa Compensation provisions of the labor Code you run
forthwith comply wit such proviaum or this permit shall be deemed invoked.
CONSTRUCTION LENDING AGENCY
1herbyelrmm the LimenhscmtsSec.3 leading agenry, for Lim perfunnuwa of
die work for which rob pennin b issued (Sec. Jo9'f, Civ. CJ
Lendefs Name
lender's Addrou
I certify, dial l have mad this application and sum that dm abom information is
' comecl. I agree to comply with all cily and county a dmames and sum laws mladng in
building construction. and hereby authorise mpmcmniva of this city to enter upon the
t above-ummiuncd property for i.,cd.a purpose.
(We) agree to save, indemnify and keep her akno the City of Cupertino againat
I IiabiliUes,judgmeno.co[ts and exper ms which may in any way accrue again,, said Gq
in consequence of the granting of this permit.
+ NT UNDERSTAN ND WILL COMPLY ALL NON-POINT
Issued by: Date
WPPLI
O REGULA ONS.
Re-roofs
Type of Roof
Sign a Applianl/Cantrama! Dam
HAZARDOUS MATERIA DISCLOSURE
Will the appliontm to,= Wilding aavpanlatae or handle huallou material
as defined by Um Cupertino Municipal Cade, Chapter 9.13, to the Health and Safely
Caine• Section 25532(a)7All
roofs shall be inspected prior to any roofing material being installed.
❑Yes o
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or fulam b ildi captain use equipment or devices which
nithanbnesairoaauminutsu dbynheBayAmAirQualilyMamgemcm
all new materials for inspection.
Diuriul7
'
❑Yes Nu
I have mal the hasabau maurlalsroquimments under Chapmr6.95 of the Califm.
nb Heal"Safely Cade. Secured 15505.25533 rob 25534.1 undo Irthe building
loco w mm.0y have • u iam. that In eamy responsibility u n die oceuput nr am
q whichMov met uivaance Cense afoc
Signature of Applicant Date
JA411.
All roof coverings to be Class "B" or better
Owns th gent base -
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Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS: el 2001=11
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100 •
GENERAL m
I am not using any
l/ ' U Signature —
Please check applicable subcontractors and complete the following
-z7 016
Date
Owner/ Contractor Signature
Date
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
om 1 of 1
100W490)M40J a 0117100 X16
I�1�1;7 a IY1�;��N1 �FM�IY
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 32344020.00
DATE ISSUED.......: 06/27/2006
RECEIPT #.........: 35038
REFERENCE ID # ...: 06060229
SITE ADDRESS .....: 11024 HOLLY TREE LA
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: DOUGLAS KNIRCK
ADDRESS ..........:
CITY/STATE/ZIP ...: ,
OPERATOR: amyw
COPY # : 2
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
OEE 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
----------------- ------------ ------------------
CHECK 84.02 23975
TOTAL RECEIPT 84.02
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------------------------------------------- -------------------
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
0
03 0,35gVF631
CITY OF CUPERTINO
WATER HEATER
CuP 1TINO PERMIT APPLICATION FORM
APN
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Buildi g Address: 6 �M 106
_mint Cccsd Owne'r's Name:
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Do 1 6\45 cV Phone#:
Contrjctor: 0 rj 010-9
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Fee ID
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