06040051 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CLINTRAC`�T40R INF,ORMATIQN BUILDING ADDRESS: PLUMB IN TIME INC PERMIT NO,06040051
22460 57L ANDREWS AV
OWNER'S NAME: PERMIT ISSUE DATE
MCCORMICK LONNIE W AND JUTIA E360 MEMORIAL 2006
NE: SANITARY NO. CONTROL NO.
(866) 293-3031
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+Op LICENSED CONTRACTOR'S DECLARATION
an FF I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
�z9 with Section 7")ofDlvisimn 3 of the Business and Professions Code,and my license is
'may
fill it flict.c 3 0 REPLACE HOT WATER HEATER/ 40 GAL GAS TALL
g,nz Ucenm Cl Lle.a
�FDans: ComDW he
ARCHITECTS DECELTs RATION s N
9,4i
i 1 undersand my Plans shall be used as public rcemds pl�'�jR®�
ado 7�rF s ®LE
e o Licensed Professional
q 5 OWNER.BUILDER DECLARATION
A<s I booby affirm on I I .Business
from the contracfemmustofs c:cruseAny c Law for oto
no fallowing uiostia(Sedan]031.5. , RMI. and Rvfestluns Cade:My cm or roomy
which requires n permit to couvuca pplic improve demolish.t,car mash any structure 500
5iy
prior bits tensed paiw requites the,
ovisio so roe such rami'Licem,file a Law mitemenChap.9
<
that he ingwitPurmanlwNeprovivismofNeConOiness ndProfeaw(Chodtet9 Sq. Ft. Floor Area Valuation
r 5 0 (cat he is
(commencing with Section 70W)of Dubs for of NC Busalleged
c sand on.Anyavi Cade)of
y 5$ that be u eumpt therefrom and U¢baso for Ibe alleged...mpdm.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil finally of --------------3;kP1V0lWrWb& c paney Type
not mare than five hundred dollars(5500). LJJ
1,uowmrofd pmpmty,armyemplayemwithwagsutheirmleeompenadon,
will dourewar'Code:
Communities
Lt. ma.it mr 1apply in an viaineu Required Inspections
and Property
who
Code:TM Canuutofs License Law dao not apply to an owner is q p
property who builds vi improves Narcan,and who deessmh work orri fffar Wr We his
awn employees,provided that such improvements are not intended meoBemd for owmor-
however.the Wilding ft or improvement le hatd within ate yes o(i m rove fa.Ne ownen
builder will have Uc burden of proving that bo did not build m improve for Oufpue of
ale.).
❑1,as owner of One property,am exclusively contracting w'iN licensed contractors w
ems met on:project(Sec.7044.Business ave Profaniau Cade:)The Contractor's Li.
came law dons not apply to an owner of property who Wilds or improsv thereon.and.
who contracts far such Projects with a contractor(s)licensed pursuant to the Contractor's
Uci nsn Law.
1 am exempt under Sep .B At P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
41 0 1 hereby afro under penalty of perjury one of the fallowing declarations:
I ham and will maintain a CeroOeam of Cotsenl to sl6insure forWorkers Compcm
some.as provided for by Section 3700 of tha labor Code,for the performance of the
work for which this Permit is issued.
❑I have and will maintain Workers Compensation Imuramx,as mquimd by Section
37W of the laterCode.for Ne porfarmeme ofthe work for which Nis permit ie iasmd. '
My Workeh ComaIomicatt leaso carrier and Policy number ) rf
Cartier. l�M l_ an¢ Policy No.: ")tet 2 (`( `I'V
CER�FlCATE OF E%EhIPIION FROM WORKERS'
COMPENSATION INSURANCE
(This malum used notbo completed Role,permit u foram hundred dollars($100) a
,or loss.)
I certify that in the perfonnamc of the work for which this permit is issued,)stall nal
employ any pormn in any manner m as to become subject o one Wmken'Compcnus0mn
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this CeniOcue of Exemption,you should
become subject to the Worker's Compcasadon provisions of the labor Code,you most
.J z forthwith comply with such provisions err this permit shall W deemed owuked.
Z in CONSTRUCTION LENDING AGENCY
(-� IWmby air,.that Nero is.conametinn lending agency for the perfarmanni
E
Ne work far which Nis permit is issued(Sec.3097.Civ.C.)
W Q lender's Name
z I<ndees Address
U Q 1 een ify that 1 have read this application and sum that the above information in ,
(y F come I agree to comply with all city and county ordinances and sate laws relating to
OU building construction.and hereby authorize mpmmnatives of this city to enter upon the
above-mendtp
umed properly for inspection puoses
9L (We)agree to save,indemnify and keep harmless the City of Cupertino against
y liabilidm,judgments.costs and expenses which may in any way accme agaiut said City
t.3 z in consequence of the granting of this Permit. (�
^" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGULATIONS.
: -ty�e� E � Lf— I(— CC. Re-roofs
Signature of Appli HAZA DR OmUS MATERIALS DISCLOSURE Data
Type of Roof
Will f applicant mf future Wilding occuper ,tswm or hawle hamdous material
as deBocd by d¢Cupertino Municipal Code,Chapter 9.13.and the Health and Safety
ewe,Section 2155324)]
0y. 5;140All roofs shall be inspected prior to any roofing material being installed.
Will IW applicant or future Wilding acupam Me cquipnsent or devima which If a roof is installed without first obtaining an inspection,I agree to remove
emit hoYAmous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District? L�
❑Yes y_l Nu
1 have teat the hvatGwsmatcrials requirements under LTapW 6.95 of the Califon
nia Hcalth&Safety Cadc,Scniam7 M5,25533md25334.1undarsandd ifNc building
dons not currently have a IOINI that It 4 my respartubilily to rmdfy dr'mecupNl of the
Ms.i c a which must W me poor w issuance of a Corti coo:of Occupancy.
l�C-�� &_I I _ CQ� Signature of Applicant Date
Owner or awhoriood agent Dale All roof coverings to be Class "B"or better
sm
Community Development
10300 Torre Avenue
Zld
jjj
Cupertino CA 95014
Telephone(408)777-3228
CITY Of Fax(408)777-3333
SCUPER,TINO
Building Department
JOB ADDRESS: PERMIT
2 2 L- l sv.. ,� j�-ew 0-e c9r!0 K
OWNER'S NAME: L¢� ,, ; c -�; PHONE # 4ggP - q4� --Z? S �/
GENERAL CONTRACTOR: (/ FAX #
I am not using any subcontractors: CQ—�� L( A /(0(;
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 tl T �2 2—T
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile pp �
• c
Owner/Contractor Signature Date
CITY OF CUPERTINO
am 2 of 2 PERMIT RECEIPT OPERATOR: amyw
COPY # : 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35603002 . 00
DATE ISSUED. . . . . . . : 04/11/2006
RECEIPT 4 . . . . . . . . . : 33925
REFERENCE ID # . . . : 06040051
SITE ADDRESS . . . . . : 22460 ST ANDREWS AV
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : MCCORMICK LONNIE W AND JUTTA E
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3961
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
•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
----------------- -------- ---- ------------------
CHECK 168 . 04 22160
TOTAL RECEIPT 168 . 04
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
CITY OF CUPERTINO
WATER HEATER
CUP I�_ '0 PERMIT APPLICATION FORM
APN#
Buildin Mss:
Owne#'s Name: Phone#:
t Q- QcR-
Contractor: License#:
Cont a t: Cupertino Business License #:
Buildi g Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
qu Cal
Resid tia Commercial ❑
Cost of Project:
• Strap d On Platform KI Bonded El
New Location ❑ Replacement
Qty. if
Appli,able Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
Plumb-In-Time, Plumbing Services
A Div. of Metro Mechanical, Inc.
360 Memorial Drive --Tr— I yC)
Crystal Lake, IL 60014