06040048 CITY OF CUPERTINO $ rnTm*vT� r• M# `�"
BUILDING DIVISION PERMIT ' CONTRA ,0WINFO �IATIOIV.`f::
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BUILDINGADDRESS: PLUMB IN TIME INC PERMITNO.06040048
21853 OAKVIEW LA
OWNER'S NAME: PERMIT ISSUE DAM
CARTER DONALD B ET AL 360 MEMORIAL DR 2006
NE: SANITARY NO. CONTROL NO.
(866) 293-3031
ARCHITECT/ENGINEER: BUILDING PERMIT Iwo
BLDG ELECT PLO MO
3o6 LICENSED CONTRACTOR'S DECLARATION NIOb Description
1 hereby"an Net 1 am licensed under provWons of Chepmr 9(commencing P
with Section 7w)idonium.3 of Jse Business and Professions Cade.sttl my It..is
ism tnrullraccr,MercecC�� Ltg (7 REPLACE HOT WATER HEATER/40 GAL. GAS TALL 12YR
Dammambe need
FINALE
RCHI'IECI'S DECLA ATION IN Is
f I mldcreunJ my plans ehdl M used w public records
e G 9.00
Licensed Professional
a7N OWNER-BUILDER DECLARATION APR 2ol1s
2 Q i I acro alarm that 11. exempt from tM CanmeciMr,License Law for the
O o which re moron.(Scotian 7(131.!,contract.altar. and are,de ions Cadc:Any city err caumy
$ which as issu•permit ac resthea@e improve,demolish,ri e stigmas
any sarectustatement 5
00
_Ira prioM is
ienwce.LLmmgo the lhespplmeof for Co mttee torileLaw(Clumenl
p p Nwhectmol,with
pmvitlwuofNeConuxmrsLkns¢LAw(Clupler9 Sq.Ft. Floor Area V
go (commcndng with Srnian 7000)of Division 3 of the Resonant it Professions Code)or BUIL
violon.of
_ Scction 703exempt
1 3 by�app cam(a a permit objects the basis for sihedapplmaarn m a cin. vil penalty of -
not mom than Rw hundred dollen(ML r Occupancy Type
❑L w owner of Ne prapa y.err my moployw with wager,w their sole compensadon,
will do dmwotk.W Newuaure u not rounded m offered farwlo(Sec.7014.Redeem;
and Praradams Code The Ca mmetres Lkaue Law does sal appy Nan owner of Required Inspections
progeny who builder or ire proves theroon,and who does such wank ancestor through his
awn employees,provided thatwch Improvements am notimended orolfered foreak.if.
however.the building or improvement is sold within ane year ofccmpledon,the owner-
builder will haw the binds of proving Nat M did Out bdid or Improve for purpose of
sale.).
❑I.as mare r of the property aro inclemently commuting with accrued amoscwr,m
canstroct the project(Sec.7044.Business and Professions Cade*To Commexces U.
cense Law does not apply m an owner of property who builds or improve thereon,and.
who command for such projects with o comamunr0)licensed pursuant to this ConmulorY
License Law.
❑Run exempt under See .B d:P C for this reasen
Owner Dam
WORKERS COMPENSATION DECLARATION
I hereby aRirm under penury of perjury one of the following denclanlions: ,
1 have and will mainWn•CeNOamaf Consent an self-imwre for WorkcesCompen-
wtion,it proviMA fm by Section 3700 of the Labor Code,for the perlormencc of tK
wart for which this permit is iaeuM
❑1 have and will maintain Worker's Compensation Insurarcc,w required by Section
3700 of lha labor Code,for the performance of the wads for which am,permit is issued
My WorYd Compenwtiav Wurencc ccan sad Poliry number am: -
Cueer: f CaC_
Policy No.: (4 PC)
CERTIFICATE OF EXEMPTION FROM WORKERT
COMPENSATION INSURANCE
I
This ee ch m MW not he completed if the Permit u foram hundred callers($100)
or less.)
1 certify that in the perfermem of Ne work fm which this permit Is Issued.I OWI not
employ any person in say member an u m become wbject to the Work ewComposition
Laws of CsiifomiA Data
Applicant
NOTICETOAPPLICANT':r'after making them CeAnesof of Labor Coca,you
0 became anompbjea y the Worker o ism s"this previsions mai of the Labor r Code,you muss
forthwith comply with sOch pfovitlans w Nu Permit NOI be dOcmW tewkod
r tiCONSTRUCTION LENDING AGENCY
[-+ I hereby affirm than Nem Is comwaction lending agency for the performance of
GL the words for which this permit Is Want(See.3097,Civ.C.)
Wti Q Lender's Name
7 z Lender's Address
U O I crnlry Nat 1 hew reed this spplirm..and seem and the above Information Is
Ly F eonm I agree Or comply with OI city and county onliw¢es and sum laws relating le
0U buildingcontraction,and hereby anamire representatives or this city to toter upon the
LL) above-memi.ned property for inspection purposes.
0. (Wc)agree to on,oriental ry and keep humlew the City of Cupeninu against
fA liabilides,judgmcru.case and expenses which may In say wayacram agenst sold Cly
U Z in concomitance of the granting of this permits RUr
�--� APPLICANT UNDERSTANDS AND WILL COMPLY WITH A .NON-POINT Issued by: Date ,--�
SO C REGULATIONS.
L.C_C,,Q �--P�v Zf 1(—O* Re-roofs ��—
Signmum of ApplicwdComoomr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or finite building Ocampantnort m handle havardons material
u denned by the Cupertino Municipal Code.Chapter 9.13.sad the Health and Safety
Code.Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ON.
Will the applicant or future building Occupant use equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hwardous air canuminanu as denOcd by dtc Bay Area Air Quality Management all new materials for inspection.
Distdct7
D Ycs 0 N
1 have mal the Imeado s materials mquimments underChapter 6.95 of the Califaa
nia Health k Safety Code,SOctirsu 25505,25533 mul25534,1 undersurel than from building
door rot cmrtntly have•tenana duan it be my respeadiniby to nodfy the occupant of the .
rtyu' menu wnlon muss met pnarm himmucoracciuncoccrocwpecy. Signature of Applicant Date
l IycA.t j J-/ - (I—I:% All roof coverings to be Class "B"or better
Owner m wthodvcd egem Dam
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
WUPEkTINO
Building Department
JOB ADDRESS: PERMIT#
2. � \/t� v d ,6 0 c�( oa 4
OWNER'S NAME: �� �, PHONE #
GENERAL CONTRACTOR: T ,`we FAX #
I am not using any subcontractors: ey
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 wb i v, r1 2? (o O
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
` s If / N / off
Owner/Contractor Signature Date
CITY OF CUPERTINO
am 1 of 2 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 32619100 . 00
DATE ISSUED. . . . . . . : 04/11/2006
RECEIPT # . . . . . . . . . : 33924
REFERENCE ID # . . . : 06040048
SITE ADDRESS . . . . . : 21853 OAKVIEW LA
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CARTER DONALD B ET AL
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1145
RECEIVED FROM . . . . : JASON SCHERR
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
•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
CUPS RTINO PERMIT APPLICATION FORM
AP N n co— l/''^ ^ 100 0v
Date: 1
Buildi g d ess:
1
Owne 's Name: Phone#:
(AWContr ctor
.
P\. i o License#:
Conta t: Cupertino Business License #:
Buildi g Permit Into:
Bld ❑ Elect ❑ Plumb)p Mech ❑
Job D scription:
Resid tial P Commercial ❑
Cost o Project:
Strapp d Wh Platform vi e Bonded
• New cation ❑ Replacement
Qty. if
A li able Fee ID Fee Description Fee Grou
BPWHEATER I Water Heater/Vent BUILDING
PPERMITFEE Plumbin Permit Issuance PLUMBING
BENERGYEner BUILDING
BUSLIC Business License BUILDING
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