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CITY OF CUPERTINO
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CONTRACTOR INF,ORMATIQN
BUILDING DI -VISION PERMIT
BUILDING ADDRESS:
PLUMB IN TIME INC
PERMIT No. 06040049
2
OWNER'S NAME:
PERMIT ISSUE DATE
WANG STEVE K AND LESLIE L
360 MEMORIAL DR STE, 140
04/11/2006
NE:
SANITARY NO. CONTROL NO.
(866)293-3031
ARCHTTECr/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I wreby affirm Nm I am licensed under provisions of Chapter 9 (commencing
with Section 7") of Division 3 of the Business alb Prmfeiswns Code. and my wense u
in Troll tmrce ante a(Qce�(�
REPLACE HOT WATER HEATER/ 50 GAL GAS TALL 12YR
Lier.se Class Lie"
T Conua:CL
ARCHITECTS DE CIA ATION
1 undcrwnJ my plans shall be used as public rtcnrda
Licensed Professional
OWNER -BUILDER DECLARATION
1 naso .(Sero Nat I a1. =crept from Ivo Contractors License Law for the
following mason. 11 031.5, Business and flofesdom Code: Any city or musty
fig n�
fit%
pumis .mss alar, improve. demolish, ri repair any stmctum
whim requires emit 1
tj
issuance. re the
pnowire nsedprsuamquitw theapplicantfor such Contrctoitmfiensele a iaw (Chapter
thmwrlingwitpursuau0theorDiviomo(the
Sq. Ft. Floor Area
luation
eBusinessancenseLaw(Gaptm9
Professions CMe)or
(commenting with 7000) Division3 of Neeged
easmd
Nu w u damps therefrom and aper We alleged esempUm. Any violation of
or it
Section 7071.5 by any applicant for a permit abjttu the applicant m a civil penalty of
F
Cy Type
not mart Nan five hundred dollars (5300).
❑ r, u owner of thie property, or my employees with wages pe Iw'tsole compewthon,
C`�.
'�"
Required Inspections
will eo the work. std Ne structure t not Intended or offered forsole (Sec. ]Oa, Business
And Pmfesdnns Code The Contractors Livatre Law does rot apply w an owner of
Property who builds o improvesthemen, and whodoes suchwmrkhimself or through his
own employes, pmrided that such improvement art rot intended omffered fowl, If.
however, the building or improvement u sold within one your of compleu0n, the owmr-
builder will have the When of proving Nat w did not Wild or improve for purpose of
ate.).
El 1, A owam of she property, Am =elusively comiuting wit licensed contractors W
cmnstmct the project (Sec. 7064, Business and Prefcons s Code) The Cmmanor s%U.
cense Law does not apply w an owner of property, who Wilds or improv thermal. and
who contracts for such projects with a eonormoo(s) licensed pursuant w the Contractors
License law.
❑ I am ....... der Sec. . B & P C for this woo
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby Anne under penalty of perjury one of the fallowing de:lmadou:
I have and wap roam sin Acertifi=te of consent to aelr-imam Me Workers compen-
sation, u provided for by Section 3700 of the Labor Code, for the pcoorm m¢c of Nes
work for which this permit is issued
❑ 1 have and will maintain Worker's Compensation Muuance, a mquime by Section
37W o(the labor code, rte the pertormarce Uu wok (or which tht permit is Issued
My Werke as Compenszhmn Ms... comer and Policy numwr are:
1'
Carrier. Policy No, b LQ ( 4 4 t7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crisis section need not w core Iced if the
OT' p permit is formnc hundred dollars (g 100)
a
nr1=a)
,
1 anify Nm in the performance of the work ism which thia Permit r Wood. I shop not
employ any Person in my manner an as w become subject to the Workers' Compensation
Laws of California. Dna
Applicant
NOTICE TO APPLICANT: If, afar making this Certificate of Eiemption, you should
become subject w the Workers Compensation provisions of the Labor Codes, you must
comply with such provisions o Nu permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby, affirm does dirt is. m.d.n lending agency for Ivo perfmrmanec of
Nes work for which this permit r issued (Sec. 309], Civ. C.)
Name
Under. Addw
I anify that I have read this application And show that the own infmmauon u
I agree w comply with all city and county ordinances and sum laws relating to
building construction. and hereby aatbona repnocnutivw of thiscitym color upon ft
Wve-mentioned property for inspection purposes.
(Wes) agree w ave, indemnify and kcep harmless the City of Cottonton against
liabilities. Judgment. colo and..peves which may M any way accsuc against and City
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOUlllCilREGULAnONS. r,
Re -roofs
Y, c—, JV_��- 4--((-
Signature
Signure mf Appli Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future Wilding .,.law. or handle heallow material
As defined by the Current. Municipal Code, Chapter 9.12, and the Health and Safety
Code. Se 25532(a)?z(a)?
❑yes
Yes pK
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtainingan inspection, I
Will thea liesnt or future Wilding occupant we equipment
PP E P Proms or devices which
agree to remove
P g
mitict? nes air conoeminant u JCOncd by Nes Bay Ama Air Quality Management
.
all new materials for inspection.
District?
❑Yes pNu -
I have mad the haaNmumateriaW requirement under CWpwr6.95 of t e Califor-
niaHurt& Safety Code, Sections 25505.25533 ad25534. 1 understood dutif Nes Wilding
does not currently have A Man. Wt it u my roaponsibility to ratify the ..Pant of the
re mment which mostw irpt poor in issuance ofa Ccmfjcam orOccu anry.
__Ff.
Signature of Applicant Date
v
All roof coverings to be Class "B" or better
owner per authonued agent Daus
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CITY OF
4fUPERTINO
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
2127
PERMIT #
060�106'c�
OWNER'S NAME:
PHONE # L(L( o
GENERAL CONTRACTOR:
FAX #
I am not using any subcontractors: �k (- I( � Q G
Signature Date
Please check applicable subcontractors and complete the following information:
Owner/ Contractor Signature
/(1 /off
Date
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
V
Plumbing
(o ;
2. 7 G O
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/ Contractor Signature
/(1 /off
Date
or2 of 2
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 36651012.00
DATE ISSUED.......: 04/11/2006
RECEIPT #.........: 33924
REFERENCE ID # ...: 06040049
SITE ADDRESS .....
SUBDIVISION ......
CITY .............:
IMPACT AREA ......
21270 RAINBOW DR
CUPERTINO
OPERATOR: amyw
COPY # : 2
OWNER .............: WANG STEVE K AND LESLIE L
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-4978
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
10FEE 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
------------
CHECK
168.04
------------------
22162
TOTAL RECEIPT :
168.04
VOICE ID DESCRIPTION
VOICE ID
DESCRIPTION
502 FINAL PLUMBING
ENERGY
506
GAS TEST
507 FINAL PLUMBING
11
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CITY OF C��
UPERTINO
WATER HEATER
�U PERMIT APPLICATION FORM
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Cupertino Business License #:
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