06080057 CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTRA.GTOR INFORMATION
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LDING ADDRESS: WATER QUALITY PLUMBING PERMrrrlo.06080057
0322 PINNNER'S NAME: PERMIT ISSUE DATE
GENE SHELL 1860 ALMADEN RD 08/09/2006
NE:
SANITARY NO. CONTROL N0.
(408) 267-9330
1A.Chn'TIECTIENGINEER' BUILDING PERMIT INFO
BLDGELECr PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION lob Description
m 1 thereby drum that I am licensed under provisions of Chapter 9(mmmcneing p
with Section 7010)of Division 3 of the Business Ansi Professions C andmylicenseu
in ran surae an tai REPLACE WATER HEATER 50 GAL
at Licen la Lk.N
Da: Canuxmr l t
'�'.f` ARCHriELTS DECI ARATION
+m< 1 undcnunJ my plans shall bo used u public incords �/
'LLy Licensed Professional D�
'03 OWNER-BUILDER DECLARATION G2.
)c s I thereby.Sero on I am uempt from Nc Canvas Code:License law for Nc
.p o following moon.(Section](131.5,Business and Profdemols horAny city m county
fm� which reyuira a permit ro Consnmcr,alar.improve,acmalish,me repair any swnure $925
zi prior suits examec,aim requima the applicant for such permit to rile aligned statement
that he is licensed pursuant to the provisions of site Contractor's License law(Charter 9 Sq.Ft.Floor Area Valuation
IH (commenting with Section 7")of Division 3 of the Business and Professions Code)or
$ that he is Meant mcmrmm and the buffs for the Alleged exemption.Any violation of
Section 1031.5 by any applicant for a permit subjects the applicant m a civil penalty of r Occupancy Type
not mom dun fiw hundred dollars(2300).
❑I,uowner ar Ne pmpenY•mr mY wployeu with wags uNeir mlewmpensation,
will dodxwams mad:he Contractors
or Law
dos not apply inan.ammoeu Required Inspections
and P wh ons Cade:The Contncmfs License Law docs not apply m an owner is q p
pmperrywbo Wildsorprovided
ssthu prove who Art not in wmthimxl(m through his
awn a however.
the u•provided Nat such improvements are not intended manered fm sale H•
boweven d building orimprovementuCold within a=year or complcuon,Neawner-
.]A.).rwits lose the bvdm of proring that he did ms hila or improve sur puryose of
sok.).
❑I,As owner of me rampart,w uclusively enameling its licensed Convaaun in
Construct the project(Sec.7044.Buono and profwions Code:)The Comracbrs Li-
Co.Law dao not apply in an owner of pmpeny who Wilds or improv thereon.and
who contracts for such projects with a Conaaemr(s)0censd punmant to the ConoaemYs
Lkmsse Law.
❑I am uempt uoaer Sce. .B&P C far Nis main
Owner Da:
WORKER'S COMPENSATION DECLARATION
1 hereby aRrtn under penalty of perjury ono of the fallowing declarations:
I have and will maintain a Cenifnate of Convent in self-insure for WorkefsCamper-
sation,az provided for by Section 3100 of the Labor Code,for the performmcc of the
work for which this permit is out:d.
Q I have and will maintain Worker's Compensation InmmnCe,As sequined by Section
3100 of the Labor Code,fm the performance of de work for which this permit is issued.
My Workch Compensation Insurance Cartier and Policy number are:
Carrier: �t t N" Polity No..:�+ (��413 G
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE .
(This section reed not W completed if de permit is for one hundred dollars($100)
or less.)
I cC.fv Nat in the acrfarmmee of the work for which this permit is issued,1 shall nm
employ any person in any manner m As to become subject to the Workcni Compensation
Laws or California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Ccnilica c of Exemption,you should
become subject in the Warkcr's Com,seaauon provisions of Ne L Aw Cook.you mus
0 tor N
forthwith Comply with such provisions tor permit shall W deemed invoked.
Z� CONMUCTION LENDING AGENCY
i-. I hereby afrum man thein u a Construction k iding.,they for the pc,fmman.of
CCi 7
the work for which this permit is issued(Sec.3091,Civ.C.)
Lender's Nam,
z Lendefs Add.
U C) I Certify that I have mad Nis application and some,Nat the above information is
U, F^ correct.I agree to comply with all city and county ordinances and satva laws rtratio,to
0 U building Construction,and hereby authartre represenmives of this city to enter upon the
r W ahovc-mcnuanedpmpent for inspection percwhich m.
F 4 (we)agree to save,indemnify and keep harmless the Goy of Cupcaino against
Z in Consequence,of
eostsandof thisamay in any way accrue again.said City
U z A PLICA T ofthearanun6 of this permit.
APPLICANT UNDERSTA $A WILL C Re-roofs LY WITH ALL NON-POINT Issued by: Date
S UR E REGULATIONS.
Sill of pelican ontracmr Da:
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Neapplicut or future building eccupmtatom or handle hazardous material '
As&road by the Courtroom Municipal Code.Chap er 9.12,and the Health and Safety
Cade,Section 255320)?
Ayes ❑Na All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit havardou air contaminants as defined by me Bay Area Air Duality Management all new materials for inspection.
District?
❑Yes ❑Nu
I have real the hvarNws materials requirements under Chapter 6.95 of the Cali for
ria Health A Safely Code,Sections,25505,25533 and 25534.I mdcmuod that ifNc Wilding
does net currently have a tenm4 that n a my ponsihilisY to notify de occupmt of the
nap-hemens,which moo or Bacto ias on cerdr:ale araaupmcy. Signature of Applicant Date
Game or uthen. rot
Date All roof coverings to be Class "B" or better
CITY OF CUPERTINO
�m 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . 1 . : 36947006 . 00
DATE ISSUED. . . . . . . : 08/09/2006
RECEIPT # . . . . . . . . . : 35562
REFERENCE ID # . . . : 06080057
SITE ADDRESS . . . . . : 20322 PINNTAGE PY
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER GENE SHELL
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : WATER QUALITY PLBG
CONTRACTOR . . . . . . . : SATALINO, MARTY LIC # 21526
COMPANY . . . . . . . . . . : WATER QUALITY PLUMBING
ADDRESS 1860 ALMADEN RD
CITY/STATE/ZIP . . . : SAN JOSE, CA 95123
TELEPHONE . . . . . . . . : (408) 267-9330
•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
METHOD OF PAYMENT AMOUNT NUMBER
---------- - - ----- ----- -- ----- ------------------
OTHER 84 . 02 VISA
TOTAL RECEIPT 84 . 02
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
502 FINAL FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�CUPEKTINO
Building Department
JOB ADDRESS: PERMIT #
2b32Z �i nY1tz� -1
OWNER'S NAME: PHONE #(Qn- - 8q
GENERAL CONTRACTOR: F
�I am not using any subcontractors:
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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile 4--
r
Owner/ tractor Signa a Date `
OCDoOEM5-7
CITY OF CUPERTINO
WATER HEATER
• CUPEI,TINO PERMIT APPLICATION FORM
APN # �r ` �ncao Date: <K� g
Building Address: /
Owner's NamePhone#: 3 --
29
Contractor: Phone: License#:
3c>>�
Contac Phone- n 3 Cupertino Business License#:
1 1
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
w
Residential [%— Commercial ❑
Cost of Project: q z "o
Strapped El On Platform 13 Bonded E]New Location ElReplacement El
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/ Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
/ BENERGY Energy BUILDING
BUSLIC Business License BUILDING
•