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08030026 CITY OF CUPERTINO t- ' �•x .�� 'do#t `�''�"�' ami' v'a �` BUILDING DIVISION PERMIT 00: "J, <. PERMIT NO. Bu1LDItc�D ss RANDY LN AFFORDABLE WATER HEATERS & 08030026 OWNER'S NAME: PERM[[L411E DATE. ROGER & KATHLEEN BLUME 24707 SAN FERNANDO RD 03/06/2008 NE: SANITARY NO. CONTROL NO. ARCH3TECT/ENGINEER: BUILDING PERMIT INFO REPLACE WTR HEATER BLDG ELECT mums MECH pp LICENSED CONTRACTOR'S DECLARATION ,lob Description ed 1 thereby Nns reby affirm 1 am licensed under provisioof CMpwr 9(Commencing P with Section 70f)0)of Division 3oftdm Businev wrA Profession.Conk and my licensee in full force and eB x !V v�z License CJa _L1.1 t-w Dam Canine WN ARCHr1ELTS DECLARATION I understand my plans shall he used do public records yU oLicensed Profcssianal OWNER-BUILDER DECLARATION 3 1 mRby.(Sa that 1 1. exempt from the Canons,Co License Law for the :OC (allowing meson.Permits 703 tin Business and ve detinns Code:Any city or county m which rtqulms n permit re tires the alter,improve such deermitt ore pair any shommnurt !=�, prions its issuance.also requires the applicant forsuch permit¢fileasigned sulvnem < that Wislicensed poauentrothe previsions ofNcContractor's IdecnscLaw(chapmr9 Sq.Ft. Floor Area Valuation iH� (commencing with Section u]000)of Division 3 of the egadBusiness c and Professions Cade)or ? S el he u exempt shcrtrrom and the burn for the ds,the exception.Any it pare ort of Section7031.3ve any applicantfor a Permit nbjecu the applicant to acivti pvulty of ApN Number Occupancy Type nm mom man five hundred dollen(5500). Luownerk.kind ipeimuchure amyemployee with wageu Heirsole Campmuiness .it da Jmwark,Lod JR Too Cmc ila rials Ljoed,Law it far{E a pply(Seea s 14,..of Required Inspections and Prdfesdons Cade Tk Conuacmh Lime law doe Cot apply m an awic of 9 P propertywhod.illiilimprovethereon,andwho suressechwork him self dthrough hu awn employees,ps r,or I that ach lmprosemmta aR not ear of C mpllertd dor{aln a, however,the buil ding buden of pnmtu saidwithin ut )earofmproedagparrawrcs- bulisuer will love site burden of pmWng Nat k did nm dtiW or improve for purpose of axle.). E]1.as owtmr of dm property me rxclu{ivcly convacel with limnsed commucma m eorntruct the propn(gee.]Ora,Badness and ProressiaN Code:)The Comrinofi Li-Law does at apply in an owner of property wild Wilds or improves Nsmm,and, who cdnmacta far such Pointer with a conoscmr(s)lianxd prreuans as dm CantranaYi Lmmuc Law. ❑Iamecmpsundcr Sec ,B&PCforthu— wner Dale WORKER'S COMPENSATION DECLARATION 1 hereby arson under Pendry of perjury,arm of the following declarations: I have and will mountain aCerdriems o(Committa self-insuR(ar WorkelaCompen- workf a which ou Par mi Seaton 3]00 of tin labor Cade,far Ne pedormutm of the work for which Nis p<onit is ieued. ❑1 have and will maintain W.mn3 Cmina credos Insurance,u requited by Section 3700 or we Inbar Code,for the performance of the work for which Nis permit is blued. My Warlme Cam samw Xt Ocaaicr and Policy number a•1Wm: `�'�, 'j Cartier. g Policy No.: -G(/ / v /s' / CERTIFICATE OF F)TEMPGON FROM WORKERS' COMPENSATION INSURANCE (Thu section need Out W completed If dm permit is torso hundred Colla&(5100) or lass) I cenify that in to performance of the work for which Nis permit 4 isamd,l slWl int employ any person in my manner suss as became cabinet in the Wool Compenssdon Lawa of Cahwasia.Date Application NOTICE TO APPLICANT:If,after making Nu Certificate of Boorman.you r)muhi become{ubjea m the Worker{Compensation provisions of the labor Code,you mea .J z, forthwith comply with such pmvisimu or this permit shall k dammed Cooked. zOECONMUCfION LENDING AGENCY 1 hereby air.Cut there is a tad Construction leading agency for pefarmarce of Ne work fur which the p.is 4 issued(Sce 31141,Civ.C.) 14 Q Lenders Name D, landeer Add. U O 1 certify that 1 have Rad this application and sate that the above information Is U,F correct.1 agree in mm comply with all city and county ordinances and m laws totaling U building Cataruaion.mJ Wrebyawhonm m,ammodarsof this city to camrupnn dm above-mentioned pmperty(or impaction pngwses. (We).,me m save•indemnify and keep harmless Ne City of Cupertino again& Hres liabilities,judgments.costs and..pcnsesw Ihmay in any way scene against said City U Z in consequence of the gr n ing of his P t Date r-v APPLICANT UNDERSTAND N 1 COMPLY WITH ALL IlbjjjIN Issued by: SOURCE REGULATION �/C' �-PPpp(/ / v/ Re-roofs Signenre of ApplicoOate HAZARDOUS Type of Roof HAZARDOO LS US MATERIADISCLOSURE Will Neapplicantdr fMuni buildingacmpantscoredrlundh Holl nsmaterial e Oessmd by the Cupertino Munici I Code.Chapter 9.12,and the Hcaith and Safety Code,Scclion 25533(&)? ✓a All roofs shall be inspected prior to any roofing material being installed. 0Ye. ❑Na Will the applicant dr(inure Dui Jing occupant urc equipmcnl or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit mordant air contaminants Rncd by tin Bay Asea Air Quality Management all new materials for inspection. District? ❑Yrs Nu Ihave Coad the hvardms materialrre irtmcnu undcrCWpter G95 afthe Giifor- niaHcslth&SarnyCrdc,Samdon 545, 33 an 25534.1 unJcraLrd thai(dm Wilding Jona ont currently have a nk that 1 my r lily m mof y site Occup "the regaiRmeatowhirnma tete w4 lily ad wmyb� Signature of Applicant Date owns oraamar eCagent Do All roof coverings to be Class"B" or better • CITY OF CUPERTINO 4 ITEMS OF 32 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 316 02 070 DATE ISSUED. . . . . . . : 03/06/2008 RECEIPT # . . . . . . . . . : BS000004096 REFERENCE ID # . . . : 08030026 SITE ADDRESS . . . . . : 10698 RANDY LN _ SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : ROGER & KATHLEEN BLUME ADDRESS . . . . . . . . . . : 10698' RANDY LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : EDDIE D NALLEY 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 ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BSEISMICR VALUATION 1, 300. 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 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 518 WATER HEATER • Sl� CITY OF CUPERTINO DY03 002-(,p WATER HEATER • CUPERTINO PERMIT APPLICATION FORM APN # O Q O ;\ Date: a _! _ oe i V Building Address: (00kr R(Ahf/ty L� Owner's Name: Phone #: Contractor: Phone #: Gb!- ,5q - 7131 AfFor-dahle WAI2r �f2.gfe.rS Fax #: bbl -.1s4 - 95-& Cupertino Business License #: Contractor State License #: Contact: Phone #: b b I - Sg- o 5d•o Scott t_ifi1-!�t`ielcf Fax#: lnbl -aSq- 956 Building Permit Info: Bldg ❑ Elect Plumb Mech Residential L< Commercial ❑ Job Description: �QPlaca Wa-rQr J-�-2titer Strapped Ef On Platform ❑ Bonded New Location ❑ Replacement Er Valuation: Green Building Check must be completed and attached to this application. Green Building Points achieved: CITY OF CUPERTINO Gy WATER HEATER • CUPErPNO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Permit Type Group IPCWHEATR Commercial Water B PCWHEATR Heater/Vent BSEISMICOM Seismic Commercial B I PRWHEATR Residential Water B ti PRWHEATR Heater/Vent A BSEISMICRE Seismic Residential B PPERMITFEE Plumbing Pemut P • TRAVDOC Travel & B Documentation BUSLIC Business License B Community Development 10300 Torre Avenue -'' Cupertino CA 95014 Telephone(408)777-3228 PEI�TINO Fax(408) 777-3333 OCU Building De artment JOB ADDRESS: PERMIT# 10(99 25 (�FlN L rU � p a,!)�dd 'z-6' OWNER'S NAME: rt L--N IVS1 uw•_ PHONE # 1-10Y - -;)25-- ,?1-7a GENERAL CONTRACTOR:A(Fo rDn wi w ct l-F f FAX # 61- 2 f5-ci ra I am not using any subcontractors: K 114 6>- 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 Owner/Contractor Signature Date