06050207 CITY OF CUPERTINOBUILDING DIVISION PERMIT aCCONTIZkOTORiINF�ORMATIOIV ._
BUILDING ADDRESS: PLUMB IN TIME INC Felt..rNO.06050207
10383 TONITA WY
OWNER'S NAME: PERMITISSUEDATE
EDWARD LUENG 360 MEMORIAL DR STE 140 05/24/2006
NE: SANITARY NO. CONTROL NO.
(866) 293-3031
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLOG EI-ECT PLUMB MECH
:aa LICENSED CONTRACTOR'S DECLARATION
2w C 1 hereby affirm Nat I am licensed under previsions of Chapter 9(commencing Job Description
will,Section 7000)of Divivon 3af NCBuvnm anQ Pr fcryBm Code.anysyliccnm is
m�N in fan forcemdefrece /- iV/ C(l( REPLACE HOT WATER HEATER 50 GAL GAS
Lice FINAALE®
F Dale Contractor
CHIrEC1-S OEC RATION
l w U 1 uMcnuinJ my pWs shall he until as public raards
a G In Licensed Professional c
OWNER-BUILDER DECLARATION J
E I herchy affirm that i......'a from the Camractors License Law far the JUN 2 C000
pas O following moon.(Section 7(81.5,Business and Professm iuCalc:Any city at county
which requires a permit to construct,alter,improve,demolish,m repair any suuctum $5 O O
-z< priortoiUWUaMe.akurcquiro Ncapplicantforsuchpermiuorileasigncdsu=cnt
Nu he uliccnxd punvanl to the pmvisiem of the Contractor's uLenc law lChapm79 Sq.Ft.Floor Valuation
e (commencing wit Sation70)0)of Division3afthc Busimenand Prefese)or ions Codxzos,VW1 NG
I
Nat he is attempt therefrom and the basis for the alleged exemption Any violation of
Section 7030 by any applicam far a permit subjects the applicant to a civil penalty of r ILI ILI Occupancy Type
.I tome Nan five hundred dollars(S500).
I,as owner of the property,or my employees with wages;o their aide compewtion,
win do the work and the mumare is not inteMed reoffered for sale(Sec.7044.Buse"
and Professions Cade:The Contractors License Law docs oil apply to an owner of Required Inspections
progeny who bui Ids er ire proves thereon,and w ho does such work himself or throagh his
.employ..proWdcd Nat such smpmwmencs...I tnteWed aronesed for sale.If,
hawem.the Wilding or improvement is sold within use year of completion,the owner.
milder will haw the Widen of proving Nat he did not Wild or improve for purpose of
ate.).
❑I,as owner of the pmpeny,am eatlusiwly contracting with Bolted conaactors to
constmct the project(Sec.7004.Business and Professions Cade:)The Contractors Li-
Ccme taw docs oat apply o m awns of progeny who Wilds or impmw a dtemoo.anit.
who contracts for Inch projects with a contracoKa)licensed Pursuant to the Contractor's
Licence low.
❑I am exempt under See .B&P C for Nis recon
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury arm of Ne foltowinH dedentiom:
1M w andwill marry eCertifiom of Cementr Code.
Wodmrs Camp the
anon,r hick this
far mi Section 3700 0(Jm Labor Cax.for the pertormance of the
work far which Nis permit is issued. ,
1 haw and will maintain Workers Compensation Imuran¢,u required by Section
37011 of the Labor Cade,for the pc forne.cc of the work far which this permit is amid. '-
MyW/y./ge� CXMdPamfiio.WrUU accectmiilland Policyromi g!r-am:
Corti rl 4//K/^L/�1l N/J/NTeMv No v
CERTIFICATEOFFxEMPfION FRO ORKERS'
COMPENSATION INSURANCE
(This eNm need not becomplcmJ if the permit is faone,hundred digin(5100) r
or kis)
1 certify that in Inc performance of the work for which this permit is issued,I shall not
employ inypeo on in any mansterse u to become wbjcct in the Workers'Compemauon
laws of Califs mia,Dae
Applicmt
NOTICE TO APPLICANT:If,after making this Centricam of Exemption,you should
become mbjca to to WorkrYl Compcnsadon provisions of tc later,Cox.you most
,J z forthwith comply with such provisions or this pemtit shall W dcsm it rcwlred. '
Z O CONSTRUCTION LENDING AGENCY
(--� I hereby affirm dot then Liaconstmetim kndingagettcy for the infamanceuf
C4> the work for which Jus permit is solved(Sec.3097,Ch,C.)
�W A Lenders Nitric
a z lenders Address
V Q 1 certify that I haw mad Nis appncatien well suite Nat the above information u
U,f" correct.)agree to comply with all city and county ordinances and suite laws relating to
O(� building convection,and hemby authorise mprcaenuitiwa of this city to enter upon the
W aWwtmcrosamcdpmpcst(and expotma purpowhich ms
4 (We)agree to ave,indemnify and keep hamlets Bic City of Cup, against
fn liabilitia.judgmcnts.casts and cxperLus which may in any way urnmagainstmid Cty
Uz in Conuquenee a(the gran ting of Nis permit.
^ AP LICA UNDERSTANDS A WILL COMPLY WITH ALL NON-POINT Issued by: Date S 2 Le
SO ULATIONS
sumo IiantKonuamor Date Re-roofs
-
HAZARDOUS MATERIALS D LOSURE Type of Roof
Wil eapplicant or future building accupantstore or handle havardoua material
u defined by the Cullinane Municipal Code.Chapmr 9.12.and the Health and Safety
cox.SectionY.zsslua)? All roofs shall be inspected nor to an roofing material beim
❑m a P P Y g g installed. -
If a roof is installed without first obtaining an inspection,I
Will the applicant or future WiIJi aceupam use equipment or Jevim which g agree to remove P
.mit hmzrdno Lir oh arritunu as by lie Bay Area Air Quality Management all new materials for inspection.
District?
❑Ym
I have mad the hisandous materials hopincomms under chapter 6.95 ofO.Califor.
nice Health&Safety Code,Sections 253(15,23533 and 23534.1 untkrs dthm iftW building
of c ntlY Taw a tenant.the it u my rcspossibility o fy the aceupam of to
rtyai whx rousted tori lvancaaracerti mora �% Signature of Applicant Date
owner or arivcd a6cnt Dam'
All roof coverings to be Class"B"or better
CITY OF CUPERTINO
om 2 of 2 PERMIT RECEIPT OPERATOR: amyw
COPY # 3
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35914006 . 00
DATE ISSUED. . . . . . . : 05/24/2006
RECEIPT # . . . . . . . . . : 34534
REFERENCE ID # . . . : 06050207
SITE ADDRESS . . . . . : 10383 TONITA WY
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : EDWARD LUENG
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : 95014-2931
RECEIVED FROM . . . . : PLUMB IN TIME
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
*EE 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 23167
TOTAL RECEIPT 168 . 04
VOICE ID DESCRIPTION VOICE ID DESCRIPTION________ ------------
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
Sul
Community Development
10300 Torre Avenue
Cupertino CA 95014
1Telephone(408)777-3228
CITY OF Fax(408)777-3333
OUPERTINO
Building De artment
JOP ADDRES PERMIT #
060 s7c�-, 20'7
OWNER'S NAME: Q.r Spl PHONE #
GENERAL CONTRACTOR: — FAX # 7
1 am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followinginformation:
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 Signa Date
CITY OF CUPERTINO
<, WATER HEATER
• CUPEIkTINO PERMIT APPLICATION FORM
APN '1
Buildi g Address: Date:
O3 i C !�.
Owner's Name:
Lu n Phone#:
Contralet
Contact: %G;�
Cupertino Business License #:
Building permit into:
BId j❑
Elect .!�] Plumb
Job Description: Mech [fi
i r
Resid'tial V Commercial0 j
Cost of Project:
S coo •to
Strapped On Platform
Bonded
• New Location Replacement
I
Yl—
Qty]if
A IiEable Fee ID
BPWHEATER Fee Description
Water Heater/Vent Fee Grou
PPERMITFEE Plumbing BUILDING
BENERGY Permit Issuance PLUMBING
BUSLIC Ener y BUILDING
Business License BUILDING Layk-
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