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CITY OF CUPERTINO�
CLINTRACTORINFsORMATION
B41ILDIING DIVISION PERMIT
A.
aILDINGADDRESS:
AFFORDABLE WATER HEATERS 4
PERMIT NO. 06090264
7612 RAINBOW DR
,7NER'S NAME:
PERMIT ISSUE DATE
MARY CHESHIRE
24707 SAN FERNAND
NE:
SANITARY NO. CONTROL NO.
(661)259-7131
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
hereby a1Rrm that lam liecnusl under pro asio
ims of cls ser 9 (commencing
with Section 70(X)) of Division 3 of the Business and Professions Code, and my license is
infuliforcc and it 3
3�
REPLACE 50 GALLON WATER HEATER SAME LOCATION
Licence Clazs seg
Dao: Con at r
ARCHITECTSDECLAR9 ION
1 undcrsunJ my plans shall W used u public ¢cords
LllCnsCd Pn1IC5S1011aI
OWNER -BUILDER DECLARATION
I hrcby aRnn
11. cumpl (sum the Conlracmrs License [ow for Ih
on
following mason. (Section ]1131.5, BULrexs and cminns Any cityerr county
improve,
aloe improve, dcmoRN. at pair any swctum
h, at
which acquires a pumil ac enres
13 (]
Sq. Ft. Floor Area
Valuation
the e
Oat In its issuance. rsu pursuant to t e IIIc applicant for such Permitun' to rte sSigned ChNmenl
witpSationodmorevisionsof the ConssmriLfcensclaw(Cole).,
(Commis
acing widlherefrom nd of the Bmineuand PmfAny
osis Ction
that W geD f r
that he u e:empl therefrom and the thou for the alleged eaempdon My violation of
vi of
r
Occupancy Type
Section 7031.3 by any applicant for a permit subjects the spplkm In a civil penalty of
not ¢ort than firs handled dollars (3500).
❑ ICu o eompevedmn,
the propeny, er my wploym with wages az tht,
Required Inspections
work.
will do the work. and the swmureunot mmnsed craw lors1 (Sec.
B.of
The Comramstheron. License low docs rot apply If an owner
do apply 0 an
and Prolesproperty
Curbbuilds
q P
propeny who builds art improres chimp, and who is
himself art through his
own employees, pmWsetl that such em am not intended
somuits art not ear.1' ea arofferetl latitude. lf.
however. the Wilding or improvementixsaid withinone
is
ildofimprovfo,theowner-
builderwill have 0e burden of proving Ws W did not Wild art improve for purpose of
-
mk.).
❑ 1, as awns, of the propeny, am exclusively contracting with licensed comnctors in
construct the pmjcm (Sce. 7044, Business and Protesslans Cade:) The Cantraamr's Lt.
C. law dots not apply to an owner of property who Wilds or improves thereon, and
who contracts for such pmfery with a enactments) licensed Wrsuanl m the CanrmClal9
License Law.
❑ I am exempt under Sec , B h P C for Nu reason
Owner Dale
WORKER'S COMPENSATIONDEC RATION
10 1 hereby affirm under penally of perjury ane of the following declarations:
I ham and will maintain a Cat irnm of Consent an self-iuure for Worka'sCompcn-
no=. as provided for by Session 7700 of the labor Cock. for the performance of the
work for which this pcmnit is issued.
❑ 1 harm and will maintain Wmaers Compensation Insurance. as required by Section
37M of the lather Case, far Ne performance of the work for which this permit is issued.
'
My Workers Compensationn Insurance Cartier and Policy number ve: O \
Carrier. I tiQ L"'TL/ Policy No.: %
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section mod not W completed if use Permit is forme hundred dollars(SIM)
or [call
I ttnify On, in the performance of the work for which this permit is issued, I shall not
employ any person in any manner an as to Wcomc subject to car Workeri Compensation
Laws efealiroroia. Date
Applicant
NOTICE TO APPLICANT: IL shot making this Centric= of Esemption, you should
become subject or the Wartcrs Compensation provisions of the labor Code, you must
foMwah comply with such provialnu or this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a commaction lending agcocy for the performance of
the work for which Our permit is issued (Sec. 3997, Civ. C.)
Lensers Nam
,
Lenders Address
I certify Nal l have mad this application am scale that the shove informatiun is
correct. [agree to comply with all city and county on it uess and slate laws relating to
building consuuction, and hereby authorize representahms of this city m enter upon the
ahovcmemiuned property for inspection purposes.
(Wc)agree m sive. indemnify andkeep the City of,againstagainst
cosy and capcnms which may in any way ¢scree against said City
may an
in consequence
nce of the
in eaurqucncc of the granting of this permit.
APPLICANT UNDERSTAgPS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date �.2 (r' _6
SOURCE REGULATION S.�///
C&&-- 9-2t- O6
Re -roofs
Stgnuum of Applian Dao
AZAROUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant of future building occupant store of handle hazardous material
as diftnsed by the Cupertino Municipal Code. Chapter 9.13. and de Hcahh and Safely
Cose. Senior 35512(¢)7
❑Yes ❑Na
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant of future building mCupm use equipment or device¢ which
If a roof is installed without first obtaining an inspection, 1 agree to remove ,
emit haaardnW air contaminants as derncd by the Bay Area At, Quality Managcmcnt
all new materials for inspection.
District?
❑Yea 0 N
thaw mad the hazardous mamdals mquimmcns under Chapsr 6.95 of the Califor.
niaHcalN&Safety Case, Scctiws 25305.25337 anal 25S34.I unsentand thazifde Wilding
does trot currently hese a ant that it u my responsibility to notify the occupant of the
mgnimmcnu which mus✓oE rest prion imuan« aft cerarcaro of Occupancy.
Signature of Applicant Date
Xt/a-2&-N
All roof coverings to be Class "B" or better
Owaer or author agent Da1C .
em 1 of 2
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 36611036.00
DATE ISSUED.......: 09/28/2006
RECEIPT #••••.....: 36238
REFERENCE ID # ...: 06090264
SITE ADDRESS .....: 7612 RAINBOW DR
SUBDIVISION ......
CITY .............: CUPERTINO
IMPACT AREA ......:
OPERATOR: amyw
COPY # : 2
VOICE ID DESCRIPTION
502 FINAL PLUMBING ENERGY
507 FINAL PLUMBING
•
VOICE ID DESCRIPTION
506 GAS TEST
OWNER ............:
MARY CHESHIRE
ADDRESS ..........:
CITY/STATE/ZIP ....
,
RECEIVED FROM ....:
AFFORDABLE WATER HT
CONTRACTOR .......:
LEONCE ROUX LIC # 26850
COMPANY ..........:
AFFORDABLE WATER HEATERS &
ADDRESS ..........:
24707 SAN FERNANDO RD
CITY/STATE/ZIP ...:
NEWHALL, CA 91321
TELEPHONE ........:
(661)259-7131
•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
502 FINAL PLUMBING ENERGY
507 FINAL PLUMBING
•
VOICE ID DESCRIPTION
506 GAS TEST
J
CITY OF
4VUPEkTINO
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
7 � I �- �LG•'�n b p,,J �r
PERMIT #
OWNER'S NAME: Ma. r t f -k 2 S k� fe-
PHONE # Yok- a 5-3 - 4 4 N
GENERAL CONTRACTOR: ala (,Jct Vlpaiar-
f FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
60
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
Owner/ Qontractor Signature
9-a�s-oy
Date
E
a
CITY OF
CUPERTINO
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
cLeua ca (011
APN # �3 COLO —1 0 3U
Water Heater / Vent y
BUILDING
Date:
Building Address:
PLUMBING
BENERGY
� �I.� 2air,be�J
ter.
BUSLIC
Owner's Name:
BUILDING
Phone #:
(,n rnr i C,1, QS rC
`{ 05'- a,53 - V Y `13
Contractor:
Phone: (rte i
License #:
ab e- o. -re ec�re.rs
aS-1 -3 13 1
to a--) 318
Contact:
Phone: to b t
Cupertino Business License #:
coif Li1TEe(: eId
5 a5av
a(0�1So
Building Permit Info:
Bldg ❑ Elect
Plumb I(
Mech E�'
Job Description:
RePEace .50 anon
Wq%f HeATer
(Sgme 1oVar.Oh = CC.rct e
Residential Commercial ❑
Cost of Project:
E3oo�
Strapped ❑ On Platform Bonded Er
New Location ❑ Replacement Er
Qty. if
Applicable Fee ID
F^PP. Dpzp.r'intinn
BPWHEATER
Water Heater / Vent y
BUILDING
PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING
0