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BUILDING DIVISION PERNLiTCONTRACTOR
BUILDING ADDRESS:
AFFORDABLE WATER HEATERS
PERMITNO-06060116
21887 SHATTUCK DR
OWNER'S NAME:
PERMIT ISSUE DATE
HAMILTON RICHARD
24707 SAN FERNANDO
06
NE:
SANITARY NO. CONTROL NO.
(661)259-7131
ARCNIIECTIENGINEFR:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECN
LICENSED CONTRACTOR'S DECLARATION
1 affirm Nat i am licensed under of Chapter Y (commencing
- Job Description 0
professions
of Division 3 o NC Businm and Pro(cuions Code, and mylicenreu
ion 7 and
with Section
��
mfull and IT
am erre _3L 2736fS
WATER HEATER 40 GAL
LED
ale C, Lca
Liccnm CI
M{(r�$t@{
Dalt (.'OnlrXbf
/RI�EPLACE
'
ARCHITECTS DECLAR ION
`—
l understand my plans shall W =it as public reenrds
n c
JUN � �110U
C('
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby aRrm Nal 11. es.mpt tram the Canaama law for We
o e; Any C
following reuon. (Secuan 7117 L5, Business and Pmfessiuns CO(c: Any city m county
Mun
whorh, iGU1R1 ] Impmsu hCmORN, Rpalr WUCWR
f0 e0ms
e..l. the.,pli, fi nd
mQ0 LIM NC appheNf for such ractur 10 fllc a algae(Chapt enl
that! LLI its l ce nsed pursuant
OhuWWlicenwd tursumn 70 00)
Sq. FL Floor Area
Valuation
of Division 3 of eBuacoomandeneclamas Codrer9
(commencing with Section 70nd of Division J of We ess.a0 Codc) of
egad on. Any vi
Nal he u exempt NWrt(ram and We buts far We alleged eumptian. Any violation of
r
Occupancy Type
Section 7031.5 by airy, applicant for a permit subjects We applicant m a civil penalty of
not mart than Bw hundred dollars (M).
❑ 1, u awes of the Property. or my employees with wage u thew sal) compensadoa,
Required Inspections
win do We work, and Wesmebreis but inendedoroffend for sale (Sm.7044.Business
and Pmfes m" Cod.: The ConuXer's Lune Law 7070 act apply W an Owner or
9 P
Property who buildsorimpmves Women. and who doessuc0wark himselforlhmugh his
awnemployees,provided Nm wellimismld ruarc nalintendedopk?w,fors.le.lf.
huildn" theav Wing orimpmwmenru sold withinone yeti ofc
Improvepurpose of
builder will love We burden of pressing Walk did not Wild or impmw Ire puhpou Of
.it.).
L., ownef of We Property, am eaclaLvely mouraeling MN licensed COnaX10r3 b
cons racl We pmj= (Sec. 7064. Business and Pmleeimns Code:) The Contractor's Li.
ecru law docs not apply b an owner of property who Wilds or improves Women. and
who contracts for such projects with a conuaclor(s) licensed pursuant b the Contractor's
License Law.
❑ Iameaemptundersee. .B&PCforthisr.tson
Owner Dae
WORKER'S COMPENSATION DECLARATION
I hereby aRna under penalty of perjury One of the fallowing declarations:
I haw and will maintain a CertiOore of Cons.nl b self4stim, for Wo lom.Campen-
sadan, u provided for by Section 37M of We labor Code, for the per(ommlee of the
work for which this permit u issued.
❑ 1 haw and will maintain Work.Ys Compensation Iaroufanee, u rtyvired by Section
3700 of We Labor Codc, for We performance of the work for which this p .I, u issued.
'
My Worker's Compensaftiion-Inwmom carrier and Policy number art:
L 7
1
Cartier. ' i 1 r' `� Policy Na.: Z �7 0
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Diu aced.. need MI W compleWd if Ne permit Is farm. hundred dndua (SIW)
or less.)
I C.nlfy Na110 N. Performance of We work for which But permit, is Wood. I ]bill .1
employ any person in any marrow u to become subject W the Workers' Compensallon
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Cerificale of Emo tOitn, you should
Mc... subject be N) Worktr'a Corrpenaad00 pmrlNWa of We Inde Code. you meat
forthwith comply with such provision er Nis permit shall W dcem<d Icwk.d.
LENDINGAGENCYi
I thereby War WerRUCT10N
War Nem u construction lending agency for the perfunnamx of
whaffirm
s
work, for which this permit ti iritic( ($a. 3097, Civ. C.)
Le
Lender's Nam)
1<nder's Address
1 certify, Nat 1 have read Nis applicator aM s.W this Ne aWw oformation u
Co.,. I agree 1n comply with all city and county oNi. and sure laws Misting to
building construction, and hereby authority mpresemaives of this city to enter upon the
aWv)-m.ndan)d ureters for iaale Mai pagloses
(We) agree to saw, indcmmfy and loop harmless Be City of Cupcnino against
liabilitiesjudgments,costa andu nus whichmay Wanyway acme gainstsaid City
in museca se of Ne OutNis permit.
APPLICANT D A AND WILL COM WI ALL NON -POINT
Issued by: Date
SOURC GU 0
Re -roofs
Type of Roof
Signuue atApplicaudoiComosem, Deal
HAZARDOUS MATERIALS DISCLOSURE
Wil11W applicant or future building no mplum a.. m handle hvallolu material
asdc0n.d by Om Cupertino Municipal Codc, Chapter 9.11. and the Hea1N and safety
Code Schon 25333(.), pr pfil�
All roofs shall be inspected prior to any roofing material being installed.
Will We applicator or turum W' use m dMana which
pP g
If a roof is installed without first obtainingan inspection, I agree to remove
Pe
by the Bt
)mil horardnus air cmuminants )fined by the Bay Arca Air Quality Management
Area Air Qu
all new materials for inspection.
DiWiCl7
QYa ❑Nu
1 haw Mad We haaarduus maerials requirements under chapter 195 of We Califor-
.iaH.1W& Safety Code, Been. 25503.25K33 and! 5334. I uMcrswd Naz ifde Wilding
does not )uncal haw . W. It y responsibility, W reify the occupant of We
mwirementawthh W prior stuare.ofaCerirl WdrOccupancy,
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner or..Wmfi�d age., Date
om
CITY OF CUPERTINO
4 of 5 PERMIT RECEIPT OPERATOR: amyw
COPY # : 2
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 35614005.00
DATE ISSUED.......: 06/14/2006
RECEIPT #.........: 34855
REFERENCE ID # ...: 06060116
SITE ADDRESS .....
SUBDIVISION ......
CITY .............:
IMPACT AREA ......
OWNER ............:
ADDRESS ..........:
CITY/STATE/ZIP ...
21887 SHATTUCK DR
CUPERTINO
HAMILTON RICHARD
RECEIVED FROM ....: AFFORDABLE WAT HEAT
CONTRACTOR .......: LEONCE ROUX LIC # 26850
COMPANY ..........: AFFORDABLE WATER HEATERS &
ADDRESS ..........: 24707 SAN FERNANDO RD
CITY/STATE/ZIP ...: NEWHALL, CA 91321
TELEPHONE ........: (661)259-7131
*EE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC
BENERGY PERMIT FEE 1.00 34.86 0.00 34.86
BPWHEATER PER HEATER 1.00 10.79 0.00 10.79
PPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37
TOTAL PERMIT : 84.02 0.00 84.02
VOICE ID DESCRIPTION
502 FINAL PLUMBING ENERGY
507 FINAL PLUMBING
n
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NEW BAL
0.00
0.00
0.00
----------
0.00
VOICE ID DESCRIPTION
506 GAS TEST
06/15/2006 10:44 FAX 408 777 3333
o
�WPEI�TINO
i ILCIing
2.1�� 9Y� attuc�Dc=
Cl'IY UuYhNIlNO
xI am not using any subcontractor��
Please check applicable subcontracto
64
SUBCONTRACTOR
Cabinets do Millwork
Cement Finishing
Electrical
Excavation
Eencin
Flooring: Carpeting
Linoleum / Wood
Giw / Glazing
Heating
Insulation
Landscaping
Latitixtg
Masonry
Sheet Metal
/ Wallpaper
Plastering
U51"tntal
nktalck
• Owner/Contractor Signatt re
in UVJ/UU*
Community I -evelopment
10300 Tme Avome
Cupatmn CA 95014
Telephone(403) 777-3228
Fax (40 t) 777-3333
Departmer t
w Li �Vu LFICr 4K AVUUVVUM uuvrmanc 1
BUSINESS NAMEBUSIAI ESS LICE NSF 4f
//T/GG
Date
£'d ££££LLLB0bT 01 0SSS T£9 0S9 d3H N31UM 3-13ti0J033C:W0J9 CTb 90 9002-9T-Nf1f
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CRY OF
CUPERTINO
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
APN# —I.U6
Water Heater / Vent V
BUILDING
Date �N OL
Building Address:
PLUMBING
BENERGY
ShHTru c.k
Or.
BUSLIC
Owner's Name:
BUILDING
Phone #:
R'L,V.&,ra t4Ar �ITb
-giClb 3>7ae
Contractor:
Phone: Ve (
License #:
hffnr&bIe wovr Acrers
65J -313 ►
(Da--73be
Contact:
Phone: to b I
Cupertino Business License #:
coV Ll1TIe,( eP-
L�CrSO
Building Permit Info:
Bldg ❑ Elect ❑
Plumb
Mech ❑
Job Description:
RePIQU '-{p &0e\
W00-ef HQctTer
j+a i i 4,,, y
(5gme JeC0.Tivn etoi cr
Residential g Commercial ❑
Cost of Project:
I�k00—
Strapped On Platform ❑ Bonded ❑
❑
New Location Replacement
Qty. if
Applicable Fee ID
FPx. 17earrintinn
Par ( rnnn
BPWHEATER
Water Heater / Vent V
BUILDING
PPERMTTFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING
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