08090074 CITY CF *UPERTINO ,�:.-s
BUILDING DIVISION PERMIT ,-CON.TRACT ;
r . ' '&$.' :::.w=,ti '3x
BUIL41yc�iS.pTNPERMIT NO.
ORTHGLEN SQ FAST WATER HEATER 08090074 ,
OWNEWS NAME: PERtAT ISSUE DATE
UMIKO RACE 12601 132 AVE NE 09/15/2008
NE SANITARY NO. CONTROL NO.
(800) 454-8955
ARCHIEC PENGINEER: BUILDING PERMIT INFO
BLDGEIF.Cf PLUMB MECH
O t L O
u p G LICENSED CONTRACTOR'S DECLARATION Job Description
wifS
W 1 hereby oftimt was I am licensed under provisions of Chapter 9(commencing p
_ don?ld Y
D visianlafw Burins and Professiav Code.antlerliccnxu REMV/RPLC GAS WTR HTR
in full force and ertfwceck
j License Ossa Conk
�_ Date Contractor
e
ARCHITECTS Act weed DECLARATION
?� 1 unae.unJ mY Plans Nall bo weed!as Public rtearJs
6
Lkeved Pvfcssi...I
OWNER-BUILDER DECLARATION
]F I W mby aRno that I am exempt from Ne Contractors License Law for the
ZOO following ream.(Section 70 L5.Business and Professions Code:Any city of county
which mquis a permit W mmpruL Jus.improve,demwl'uh.or repair any sounure
prior to its issuev,em reforms the applicant forsuch Permit o rite asigned suxment
�< that W is litemcJ puraun,to the pm.imorm.fthe Conuanor.Luse.law(ChaPter 9 Sq.Ft.Floor Area Valuation
rE s (commencing with Section,7000)of Division 3offtBvinessandProf innsCook)or $449 .
s 5 that W is exempt 1Wsefrmn and the basis for w alleged exemption.Any violation of
Session 7031.5 by M'applicant for a permit subjects the applicant to a civil penalty ofyy,pgg��Number Oecu ane e
and more owns five hundred dollars(IW. 31641047 .-VV' P Y�YP
❑I,u owner of the property,of my employees with wages u their now cmnperse".
will slow wart,and the a =u hot Intended of offered far sed(Sec.7014,Business
and Pmfe�ov Cade:The Contractors i.lanm law,does Out apply W an Owner of _ Required Inspections
property who Wilds m im prove,thermn,and who does such wart himsel f or through his
lam employs.providedvouchimProwmwtarcnot year
ofdmortared the mares.bowews.we Wilding b r improvement It sold c within at build of mproeuan,Mune of
builder WR have sic Wrden of proving that W did Out build w improv for purpox of
❑1.to ow=of the Property,am exclusively contracting with licensed eortranms Is
mvtmct the project(Sec 7W.Burros and Professions Cade:)T1e Contractor.U.
coma law ds not apply W an owner of property who Wilds or improves thereon,and
who contracts;for such projects with a mnuxxr(s)llansed Pussunt to the Contractors
IJccnve law.
❑I ons exempt under See .B•P C for this mason
Owner Dam
40 WORKERS COMPENSATION DECLARATION
I hereby affirm under penny of perjury ante of the following decaratiov:
iMwandwillmeinwnaC rlmmof Covent Wself-i=mfmwm JCompen-
.tion,of provided for by Smdon 3700 of the Larios Code,for we permmmance of the
work for which this Permit is issued.
❑1 have and will maintain WmIwc.Compensation I..not refuined by Section
37000f the Labor Code,for the performance of the wast for which Nu permit is loomed
My Workers CompmaaRom wermance cartfer and Polic mandm are:
Cartier. Policy NO.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Mus occRen reed Out W completed Riad permit is forms hundred dollars(5100)
or kat)
I cenify Nat in the performamc of the work for which this permit Is issued.I shall apt
employ,my perm in any manrcrx.W Warsaw bjcolW the Wahma'Compevation
Lava of California.Date
Applicant
NOTICE TO APPLICANT:If.ex,mating this Certificate of Exemption.you should
become subject W Ne Workers Compensation previsions of IW Lahm Code,you moa
.J O forthwith comply with such provi.iov m Nu Paan shall W deemed mated.
.Pi rjl CONSTRUCDON LENDING AGENCY
Fw I hereby ofRan wt thereuacovtrwcvinn tending.goncy for the perffamanceof
(5:7 the work far which this permit is issued(Sec 3097,Cl,C.)
C Q 4Mce.Name
Lenders Address
U O 1 certify wt I have read this application and s.te that the above.formation it .
11, Fconal.l some In comply with all city.d county radimos aW sate laws rel.ling as
OU buildingmnspucdon,and hereby suhorfae repomfousive.of Nu city W cnwupnn the
Ii7 above-mensionetl property for iexPe expenses
puryoxs
y (W0 agree to.ve,indemnify and keep hamlessdm City of Copenlna agaid,
VI consequence
fonecraming expenxewhich may in anYwyacmm against paid City
U z A APPLICANT
sir thegaming of UtasD WIL
ti APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Stgnuurt of AppliexnaOonpanor Dau Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
MR sins applicant or Rupee Wilding occopammum m handle h.allons material
not defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
Code.Session11Y. "No2ss3z(,)7 All roofs shall be inspected prior to any roofing material being installed.
11 Y.
Will the,applicant offuture Wilding Oars If a roof is installed without first obtainingan inspection,I agree to remove
Pant was equipment
nl W'raNnua err conumivu u J
ncfincd by w Bay Arta Airit QQuuor device Mich ality Management all new materials for inspection.
DisWat
❑Yns ON.
I have read the hmaNassmatefiaurequi.n wmlcfChapter6.95ofRteCalifor-
nie HcoINASafetyCOdC,Sections 25505.25533 am125534.1 understand Rutifthe Wilding
Jou not certendy how a thunk RW it is my m.powibility W ondfy me Caupem of We
requirements which roup W met prior W in.of a Cenifeam of Occupanry.
Signature of Applicant Date
Owner or authorized agent Dam All roof coverings to be Class lqv or better
CITY OF CUPERTINO
• 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: pdtg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 31641047 . 00
DATE ISSUED. . . . . . . : 09/15/2008
RECEIPT #. . . . . . . . . : BS000006073
REFERENCE ID # . . . : 08090074
SITE ADDRESS . . . : 20284 NORTHGLEN SQ
SUBDIVISION . . . . ... .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : UMIKO RACE
ADDRESS . . . . . . . . . . : 20284 NORTHGLEN SQ
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-0520
RECEIVED FROM . . . . : JEFF JORDAN
CONTRACTOR . . . . . . . : JEFF JORDAN LIC # 29100
COMPANY FAST WATER HEATER
ADDRESS . . . . . . . . . . : 12601 132 AVE NE
CITY/STATE/ZIP . . . : KIRKLAND, WA 98034
TELEPHONE . . . . . . . . : (800) 454-8955
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 449 . 00 0 . 50 0 . 00 0 . 50 0. 00
1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1PRWHEATR UNITS 1 . 00 24 . 48 0 . 00 24 . 48 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 106 . 56 0 . 00 106 . 56 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 106 . 56 VISA
---------------
TOTAL RECEIPT 106. 56
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER
•
Permit No:DO o Iool 414802
(office use only) .
City Of Cupertino Building Permit Application
E-Mail: Building-Permits0cuoertino.ora (Address is case sensitive).
Jobsite Address:20284 NORTHGLEN SQUARE Date: 9/15/08
Assessors Parcel Number., 1 lv4 ic>q-7, o0
Owners Name: RACE, UMIKO Phone No: (4oapes.2s10
Project Valuation: 449.00
Building Permit Info:. Bldg_ Elect Plumb X Mach
Job Description
Remova/Repiace Gas Water Heater
Contractor Information.
Company Name: FAST WATER HEATER COMPANY Phone No:
Contact Name: Carol Randall Fax No: Boo.464-8955
• Address: 12601 132ND AVE NE E-mail:carolr®fastwateMeater.com
City, State&zip code: IURKLAND,WA 98034
State Contractors Llc. No: 877489 Expiration Date: 5/31/10
Workers Comp No:, 1761660 Expiration Data: 12/1/06
Carrier: California State Fund
City of Cupertino Business License No: 29100
Credit Card Information
Credit Cab No: X80 Expiration Date: 11/10
Name on Card: Jeff Jordan
Visa'® MasterCard ❑ American Express ❑
The Building permit application and a completed & signed
contractor/subcontractor form need to be submitted with each permit.
c�
10300 Tone Avenue
CWdrdm CA 95014
Tehphone(408)777-3228
OCUPEI�TINO Pax(408)777-3333
r '�1 Building Department
JOB ADDRESS 20284 NORTHGLEN SQUARE PST#
03
0 p OQ O ®nil
OWNER'S NAME: RACE UMIKO PHONE# 408 28.110 ( T
GENERAL CONTRACPOR FAST WATER HEATER COMP ,FAX# 425-814-0818
I am not using any subo mtracbors:_ — --- /� `�` 9/15/08
Signature Date
Please check applicable subcomt adman and cmplete the irdmnmatiOn!
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets&M hvork
Cement Finishing
Mecbkd
Excavation
Fencing
Flooring:Carpeting
Linoleum/Wood e'
Glass/Glazing
Heating
Insulation
Ladiing
Ornamental Sheet Metal
Painting/Wallpaper
P
Plmmibnlg
RiRock
g
STank
SMetal
Sheet
Tile
Owner/Contractor Signature Date
•