08030035CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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cON RAC-Tq91
BUILDING ADDRESS:
FERMI NO.
21155 OROGRANDE PL
FAST WATER HEATER
08030035 ,
OWNER'S NAME:
PERMIT ISSUE DATE
KUMAGAI SHOJI AND CAROL M
12601 132 AVE NE
03/07/2008
ONE:
SAI; ARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
REMOVE/REPLACE GAS WATER
-BLDG ELECT PLUMB MECH
1
0 0 0
LICENSED CONTRACTOR'S DECLARATION
HEATER
Job Description
under
1 hmeby am. Met 1 am licensed under provision of CMptm 9 (commc
withf JaffBusirmasaodrofmsinu aryl castle
in fullfmccand.
Lluna Cl Lk.N
Dem Contracmr
ARCHTTECTS DECLARATION
I uodentsnd my plane "I W sad as Public r..mm!
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby alDrm that I em exempt from Ne Conlumme i License law for f
following meson. (Section 703 1.5, Business and Profetioa Cade: Any city or county
which mquims a permit to eomeruq slur. impmm, demolish, or repair any structure
prior an its iawnce. also movies f applicant for each permit to file a signed 4ammal
that W'a llccneed pursuant mw provisional of w Comramll lARM1fC Law chapter
Sq. Ft. Floor Area
Valuation
hammencing with Section ]000) of Division 3 of the Business and Professions Cade) or
ones he is exempt thGrefrora and f bash, far Me alleged exemption. Any vloladore of
Section 7031.3 by arty applicants fora pemb subjects On applicant in a civil penalty a
APN Number
Occupancy �g�,�
P >'' •7Pe
nesmomduofivehundmidollasn!' }
❑ I, a owner of die property, a my voplayeu with wags u fb rola cmnpewdan,
'
- Required Inspections
will do the work, and fsummum is notinundW Muttered! forsala(Sec. 70M, Bui.
and Profeam. Code: The Carbamr! Liceme law doe out appy to an nwam of
property who bulldaerimpmv sdome, andwho doesluchwarkMmalfor through his
owe employee, provided that each improvements see not immndM oroReml fmsak. IL
however, the building m improvement Is aid within arc yrx of cumpha en, the owner.
Wilda, will have Ne burden of proving that he did an, dub or improve far purpose of
ale.).
❑ 1, as owner off prepcnY• am exclusively contracting with licensed contacmrs in
coutmet the project (Sec. 7044, Baines and Prnfmsiam Code:) The Contra tort Li-
ceum law dam at appy an an own. of propeny wW build! or Improves demon, and.
who contracts far such projects with aeontrx5nr(s) liaaad pmrnant at f Cmu ane.
License Law.
0 lam.emplunderSec. ,B&PCI.Werm, a
Dam
WORKER'S COMPENSATION DECLARATION
V
1 hertby air= under Porosity of perjury arc off following decl.ava,
shave and will msintsinaCenifiae ofCouemm elf -inure lreWorkeYl Camped-
.
colon, as provided for by Section 3700 of f labor Code, for Ne perfamanee of f
work for which this permit is issned.
❑ I he" and will ..law. Wortse. Compewtion Imuranm. as ox vied by Secuon
3700 of f la WrCode. far f pedmmmee of f work forwhich Jul perosis is lamed.
My We mpenead 1. 'artier and Policy n r /%�
Carrier. s Policy No.:—��`G�-aiacfaa�_
CERTIR TE 0 • EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thla Mellon need rot be completed [tube permit It forme Wodmd dollar (SIM)
m teas)
1 unify that In the performance of the work for which this permlt is issued, l halt am
employ any person in my mannerM n in become subject m the Wotkmx CempcnadW
Laws of califomis. Dau
AppBmnt
'
NOTICE TO APPLICANT: IL after making this Certifiam of Exemption, you should
bamoroe subject be the Workefs Compensation provisions of f labor Coda you mum
forthwith comply with each iumvtsinm or this permit shall W domed a eked.
CONSTRUCTION LENDINGAGENCY
1 bemby Or.. then for is a combucdnn landing agenry for Me perfmana of
w work for which Inas permit is laud (Sac 3097, Civ. C.)
Lender'sName
Lendels Address;
I eertify that 1 ham read We appliwion and sum Ma de above inmarmi n Is
'
cmmM. I agree to WMPly with all city arm county on ire nces and rola have misting to
Wilding construction, and hereby ambories depromman s of this city m aur uponf
above-mentioned property for Wpeodon inaptness
(We) agree an ave, indemnify and kap hamlet f City of Cupertino against
Ilobtlitim, judgments. cast and expenses which may In MY way Mro
co agsiml aid City
In consequence of due granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AI,L NQN-POINT
Issued by: Date r
SO LATIONS.
oei
Re -roofs
Type of Roof
Signature 0pplufor Data
HAZMMOUSMATERIALSDISCLDSURE
Will the applicant or futureni building haardoud material
nom wand
, Chapter the
a defined by f Cupertino Municipal Code. Chapmr 9.1; and f Health and Safety
All roofs shall be inspected prior to any roofing material being installed.
kitDes33512(')'
If a roof is installed without first obtaining an inspection,I agree tD remove
Will Lha applicant or future building occupant use equipment or devices which
he'randous air ammaminats u dc0acd by the Bay Am, Air Quality Management
all new materials for inspection.
.9 /
❑Ya
Ibaromadf KL-md mmmeHsis immenaunder, Chapurd.95ofwCalifor-
Hulth&Safcty CMM,Smiam25505,25533am125534.lmdcnwdthmiff Wilding
net cencrudy have a mnah Nat It u my mepomibility m notify f up of f
iw hmalls, Cl 'ormivuauofaGaOfcsmaq"
/�
Signature of Applicant Date
All roof coverings to be Class'W' or better
owner
or eath agent Demi
•
•
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 36217008.00
DATE ISSUED.......: 03/07/2008
RECEIPT #.........: BS000004104
REFERENCE ID # ...: 08030035
SITE ADDRESS .....: 21155 OROGRANDE PL
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA ....... -
OPERATOR: SylviaM
COPY # : 1
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT :
AMOUNT
---------------
106.56
---------------
106.56
VOICE ID DESCRIPTION
-------- ----------------------------
518 WATER HEATER
REFERENCE NUMBER
--------------------
3519
VOICE ID DESCRIPTION
-------- ----------------------------
OWNER ............:
KUMAGAI SHOJI AND
CAROL M
ADDRESS ..........:
21155 OROGRANDE PL
CITY/STATE/ZIP
...:
CUPERTINO, CA 95014-4151
RECEIVED FROM
....:
FAST WATER HEATER
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 HAL
----------
IBSEISMICR
------------- ----------
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
-----------------
CHECK
TOTAL RECEIPT :
AMOUNT
---------------
106.56
---------------
106.56
VOICE ID DESCRIPTION
-------- ----------------------------
518 WATER HEATER
REFERENCE NUMBER
--------------------
3519
VOICE ID DESCRIPTION
-------- ----------------------------
From: 03/02/2008 08:08 #575 P.003/014
4
CITY OF CUPERTINO
WATER HEATER
PERWr APPLICATION FORM
0963W,35-
395439
APN #
Date:
3/1/08
Building Address:
21155 OROGRANDE PL
Owner's Nasse:
Phone #:(408)996-8130
KUMAGAI, SHOJI
Contractor:
Phone #: 800-454-8955
FAST WATER HEATER COMPANY
Fax M 425-814-9516
Cupertino Business License #:
Contractor State License #
29100
877489
Contact=
i
Phone #: 80o -4m-8955
Carol Randall
Fax* 425-814-9518
Building Permit Info:
Bld . Elect
Plumb x Mech
Residential x❑
Commercial ❑
Job Description:
Remove/Replace Gas Water Heater
Strapped ❑ On Platfarm ❑ Bonded
❑ New Location ❑ Replacement
Valuation:
449.00
Green Building Check must be completed
and attached to this application.
Green Building Points achieved:
•
From: 03/02/2008 08:06 11575 P.004/014
CUPEkTINO
CITY OF CUPERTINO
WATER SEATER
PERMIT APPLICATION FORM
395439
Quantity
Fee M
Fee Description
Fee
Group
Permit Type
IPCWHEATR
Commorczal Wates
Heater/Vent
B
PCWBMATR
BSBJSMICOM
Seismic Commercial
B
1
1M—WHF.,ATR.
Residential Water
Hester/Vea1t
B
PRWEFATR
BSEISMICRE
Seismic Residential
B
I
PPERMrIMM
Plumbing Permit
P
TRAVDOC ,'Travel
&
Documentation
B
BUSLIC
Business License
B
0
•
0
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
I am not using any subcontractors:A 2J
116 9
SiindKire Date
Please check aoolicable subcontractors and complete the following information:
A
WWWO
• ik �. �J1
•
Cabinets & Millwork
I am not using any subcontractors:A 2J
116 9
SiindKire Date
Please check aoolicable subcontractors and complete the following information:
•Contractor Signature
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
•Contractor Signature