08080046 CITY OF CUPERTINO pERM�T T1. AI"VW- """
BUILDING D+VISION p �F�
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BUILDING ADDRESS: PERMIT NO.
21073 PATRIOT WAY FAST WATER HEATER 08080046
OWNER'S NAME: PERMIT ISSUE DATE
VI,VI.AN CHANG 12601 132 AVE NE 08/06/2008
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ GINEER: BUILDING PERMIT INFO
RMV/RPLC WTR HTR BLDG ELECT PLUMB
O
Sop LICENSED CONTRACTOR'S DECLARATION
1 hemby affirm that 1 am Iia:wN under Provisions of Chapter 9(ammneing Job Description
with Section 70fan of Diviwan 3 afdu Business W Professions Code,snd my lf.6
in full forte and effect
sg: Lieenm ahs Lm..
k,
Dam.Contractor
ARCHITECTS DECLARATION
A1 understand my Plush shall Ise used renNs u Public
yQ Cleaved Professional -
Dat I am exempt fo DECLARATION
1 hereby alarm that I em camps from the Conine,Cc :My c Law for the
p o following mmoa permit
t ID3 L5, L after,and Rafaainns Calc:My city at roomy
whim mquiry a Permit m nmstvct filer,improve,dcmolixh,or repair ay structure '
prior an its issuance.also requires the applicant per such permit m file asigned sutemat
< "Iheislicensed mosaattothe provisionaorweCommences uamLaw(Chapter 9 Sq.Ft.Floor Area Valuation
9 (commencing with Section 7000)of Division 3 at the Business and Profossiom Code)or
that he is exempt therefrom and one basis for dm aftsed aemption.My violation of
SeNon 70315 by any applicant for a permit mbjem the applicant to a civil Penalty of APN Number Occupancy Type
not roam thm five heMmd dollars($300),
❑Lasewnv oftimpropemy,or dayrmploym with sesta.dm4solemmpewdes, "
NI Profession
r Newark and Ne he Onnu not s License
as w do mreta(Sal.7014,B neer of
w property
bat cede:The Conuanon.flame leve uch et apply lf an ower ar Required Inspections
Property who nand«or ed trema themoo.and sono swat m seek nimlllfedmhale his
own employes.provided prmenimprowd witinnot Intendedmpletmd fmuk.Ir.
however,the
ss"thWilding aimprovpm Inbhatd withinoe year or imoPmforpreower-
bulkier will haw the WNa of proving Nn he did not build or improve for purpose of
sale.).
1,as owner of the property,am exclusively contracting with Removed conommn to
convect the project(Sea 7044,BYbmts and Professions Code)The Caavacnrs Li-
cent Law does not apply he an owner of property who builds or improve thereon.ad,
who contracts for such present win•comrecmr(s)licensed pwmant se the Canuxscw a
License Law.
❑Iarnmeptunderse. ,BBPCformU.
Ower Data
WORKER'S COMPENSATION DECLARATION '
\ I hereby affirm under penally of perjury one of tin fallowing declensional:
I haw and will maintain•CerrIOwm die.rom.t to Ylr-alum for Workers Creeper.
notion,Y provided for by Section 31M of the Inbar Code,for the Performance of the
wort for which this permit is isaut
❑I haw and will maintain Worker's Compensation Imunace,Y required by Section
3700 of the labs Code.for the performance of the wink for which this Work is Wood. '
My Workers CompenWlon boom a amu and Policy number art:
Camen: Policy No.:
CERTIFICATE OF EXEM MON FROM WORKERS _
COMPENSATION INSURANCE
(Ods section ted et be completed if de Permit Is for ane hundred dellm(SIOD)
or ins)
I certify that in the performance or the work for which this permit is issued.l small et
employ any Person in my curator an Y m become mbjeci to tiro Workerr Compensation
Laws of Califomia.Dau
Appliam
NOTICE TO APPLICANT.If,after making this CenlBcam of Exemption,you should
become subject to the Workers Compensation provisions of rte Labor Coda you meet
.JO forthwith with comply with men Provisioneror this permit shall M deemed mmmul,
„zt51 CONSTRUCTION LENDING AGENCY
I-v I hereby affirm thus then is a construction lending agency for the Performance of ,
ai
the work for which this Permit 4 iarA(Sec.3097,CN.C.)
WM Q Lenders Name ,
2 lenders Adder..
U O 1«miry that I maw mad this application and,tam that the anew information Is
U,^. coma ree m 1 agcomply with all city and aunty ordinances and and aIan miming to
.O SU^ building construction.and herebyaunodm repesemow:s of this city m enter upon do
tT] abaw-mcmianed property for inspecdan purposes
y (we)agree to Yw,indemnity and trop homeless the City of Cupertino against
fq Iimilitis,judgmonta,com andeapevs which may In my my acrnu against Yid City
U 7 In conmquena of the gientine of this permit
t7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of AppllaMCommuner Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or phone Wilding oaupat sere orhandle heYrdow material
Y defined by the Cupertino Municipal Cade.Chapter 9.13,and the Health and Safety
Code.Scotion29533(x)7 All roofs shall be inspected prior to any roofing material being installed.
0Y. "No
Will the applicant or rmum wilding occupant um equipment a dcviaa which If a roof is installed without first obtaining an inspection,I agree to remove
It haxandnua air cetaminsms Y defined by the Bay Area Air Quality Management all new materials for inspection.
D suict7
❑Yes ON.
I ham mW thelovartmu materials roquimmenu under Chap erti.95 of thc Califor-
niaHYl"SafetyCode.Seedans35305,35533ad25534.lundcssundthatlfB<Wilding
dee net currently haw a tact that it is my responsibility in notify the aroupmt of the
requirement,which most eemet pour to issuance ofacenifmteofarapmcy. Signature of Applicant Date
Owner mautharivcd ascot Dam All roof coverings to be Class'%(}«'or better
CITY OF CUPERTINO
• 4 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32653052 . 00
DATE ISSUED. . . . . . . : 08/06/2008
RECEIPT # . . . . . . . . . : BS000005707
REFERENCE ID # . . . : 08080046
SITE ADDRESS . . . . . : 21073 PATRIOT WAY '
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . .. VIVIAN CHANG
ADDRESS . . . . . . . . . . : 21073 PATRIOT-WAY
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5707
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
IPPERMITFE FLAT RATE 1 . 00. 40 . 79 0 . 00 40 . 79 0 . 00
1.PRWHEATR 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
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER
(u 004411
Permit No:
(office use only) I�
City Of Cupertino Building Permit Application
• E-Mail: Building-Permits aAcuoertino.org (Address is case sensitive). /
Jobsite Add ress:21073 PATRIOT WAY Date: 8/5/08
Assessor's Parcel Number 32,b!5�:5
Owners Name: CHANG,VIVIAN Phone No: (406)366-1801
Project Valuation: 449.00
Building Permit Info: Bldg Elect Plumb X Mech
Job Description
Remove/Replace Gas Water Heater
Contractor Information
Company Name: FAST WATER HEATER COMPANY Phone No:
Contact Name: Carol Randall Fax No: 800.454-8955
Address: 12601 132ND AVE NE E-mail:carolr@fastwaterheater.com
City, State&Zip code: KIRKLAND, WA 98034 ,
State Contractor's Lic. No: 877489 Expiration Date: 5/31/10
Workers Comp No: 1761660 Expiration Date: 12/1/08
Carrier. California State Fund
City of Cupertino Business License No: 29100
Credit Card Information
Credit Card No: Q Expiration Date: 11/10
Name on Card: Jeff Jordan
Visa iX1 MasterCard ❑ American Express ❑
The Building permit application and a completed & signed
contractor/subcontractor form need to be submitted with each permit.
4aCommunity Development10300TotmAvenue
Cupertino CA 95014Telephone(408)777-3228
Fax(408)777-3333
•CUPEkTINo
Building De artm.ent
JOB ADDRESS: 21073 PATRIOT WAY PERMPT#
a� 09 00 y
OWNER'S NAME: CHANG,VIVIAN PHONE# 408)366-1801
GENERAL CONTRACTOR FAST WATER�H,E�AaTTEE1R COMPA .PAX# 425-814-9516
I am not using any subcontractors:_ / � " � 8/5/08
Signature Date
Please check applicable subcontractors and complete the foIlowin information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE#
Cabinets&Millwork
Cement Finishing
Electrical
Excavation
Perking
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