05100067 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: AFFORDABLE WATER HEATERS "HaRTND' 05100067
10191 VICKSBURG DR
ER'S NAME: PERMIT ISSUE DATE
LABRAL GLENN L AND ANN T 24707 SAN FERNANDO ED in /i4/200c;
NE: SANITARY NO. CONTROL NO.
(661) 259-7131
ARCHi 2E 11INGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
goo LICENSED CONTRACTOR'S DECLARATION lb Description
ty I Money affl m that 1 Am licensed under provisions of Chapter 9(commencing
ZZ with Seetion70(10)of Division 3 of Ne Bosines,and Pm(esaiona Code,mornylicenseu
n=
Lkcin(unse Cllforclaeesandc mcg 6'9 INSTALL WATER HEATER
z
Dau Cosnnctm s
RCHffECm DEC ATION
I understand my,lase sled I M useJ as public racnrds
D�
gW
Licensed Pndcaional -
OWNER-GUILDER DECLARATION
Com uta OCT
O F 1 hereby a(rrm o n I em exempt from the Contrnclors e:Any
Law for IM / of �OD
G o following rtsson.(Section 7(131.4 Business and Improve.
d aium Cale:Any city or courtly Q
$ which requires a permit re cnnsuueL aloe Improve,demolish,or repair ed structure v 8 0 0
tprior hat
its lensed p.alwregolsp provision of for Condrermitm Hie uigned statementr9
FFp< that he is licensed pursuant to tite provisions of the Conuaclor'a License law(LTepur9 Sq.Ft.Floor Area ttQO
S� (commencing with Section 7000)of Division 3 of the B milieu and Professions Csse)or ��(lt7Rai
3 tet he is esompt tMmfrmn and the bub fn the staged mrsonoon.Any violnlon of
Section 7031.5 by any applicant fora permit subjects the applicant W a civil penalty of r• U U Occupaneygype
Amt come Nan firs hundred dollars($500).
❑1,as owner of the property,ee my employees with wiles As their sole compensation,
will do the work and the munumlanet intended mutilated Waste(Sec.7044,Business Required Inspections
and Proreaiom Cade:The Conmimuss Lt.=Law does nal apply b an owner of q P
property who built m improve,thereon.and who does such week himself or through his
own employees,provided Nal such improvements tee nothrended or offered for sale.If, a
however,Ne building or improvement Is sold within one year of completion,the owner-
Wilde,will have Ne burden of proving that he did Amt build in improve fm purpose of
tele.).
0 1,as owner of the property,Am exclusively contracting with Iicemed conectan to
construct the project(Sec.7000,Business and Profusions Cotler)The Canm me"U.
ams law does AN apply to an owner of propery who WOds or improv,Moment,and
who concocts for such pmjecro with•contractor([)licensed pursuant to the Contnetoes
License Law.
0 l am exempt under Sec .B O.P C for this moon
Dau
WORKER'S COMPENSATION DECLARATION
I hereby Affirm under penalty of perjury am of the following declan0ons:
0 1 have and will maintain aCenlOcate of Consent to self-iuum Hai Worker'sCompen-
atlon,As provided for by Section 3700 of the LAW,Code,for the performance of the
work for which this permit is issued.
0 1 have she will maintain Workers Compensation Insurance.ex required by Schon
3700 of the LAW,Code,for the performance err Ne work for which this permit is WueJ.
My Wculm I Campefnuaon In/steins aericr and Polity number
Cartier.�la ; /�[aa+0 PoIicY No.: -Z.60
CERfIPICATE OF E%EMP170N F7t0M WORKE S'
COMPENSATION INSURANCE
(This section need our W completed Hthe Permit Is fmone bonded dollan($100)
or lea.)
1 certify that In the performance of the work for which this permit is issued.I shall not
employ any person in my manner as As to become subject to the Werkcei Compensation
Law,of California.Date
Applicant
NOTICE TO APPLICANT:It.afar making this Ccniftnte of Exemption.you should
become subject to the Worker's Compemetion provisions of the Lahr Code,you most
.,O forthwith comply with such provisions or this permit Mall be dm
eeed rem ked.
'Z..i ti CONSTRUCTION LENDING AGENCY
)--A (hereby Affirm that there Is a construction lending agency for the performance of
C „>,i the work for which this permit b issued(Ser.3097,Civ.C.)
W Q Lenders Name
le Z Lendar's Address
U0 I cenify that 1 love road this application and shim that the aw.let..U.Is
W !' correct.I agme to a mpty with all city and county onfinances and sum law relating to
OE
Wilding convection,and hereby authorise representatives of this city to toms upon Me
W shove-mentioned property As Inspection purposes
gy (We)agree to an,indemnify and keep homeless the City of Cupcnino agaiml
N liabilities,judgenc u.cute and expenses which may In try wry aceou against said City
U 7 In consequence of the Darting of this permit.
A� APPLICANT UNDERSTANOS AND WILL COMPLY WITH ALL NON-POINT Issued by; Date /0—/3-04--
SOUR �y�Uy� ONS. J f
SO=
/��T' i /0/ r/ Re-roofs
Sig umo ppHcanVCantmmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant store or handle huardous mamriai
As defned by the Cupertino Municipal Code.Chapter 9.11.and the Health and Safety
de.Sued.25532(g7 ^,` All roofs shall be inspected prior to any roofing material being installed.
0Yes Wit
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emll hazudou sir conumimnIs u do d by the Bay Ares Air Quality Management all new materials for inspection.
District?
O Yes u
1 have med tee haardousmeuriab requirements under Chepmr495 ofthe Califor.
nit Health@Safcty Codc,Section,25505.25533 and 23334.Iminumand Lqp#ft Wilding
does not current hy1{•want,dot It is my pomlNlity to AAodr occupant of the
requiremeflu.uAjurySdusv6E metpriarroi Cervine, emp.ney. Signature of Applicant Date
Owner o��t�i harrind/✓a Jeennntt( '/ Data All roof coverings to be Class"B”or better
CITY OF CUPERTINO
WATER HEATER
OCUPEkTINO PERMIT APPLICATION FORM
APN# 3401- o:7 - x5
Building Address: l
/00/ LV,S
Own is Name: Phone#:
-7Itcr.i �'i C �3r� l ofs-asa a5Y
Contractor: pp Phone: License#:
Contacct: Phone: Cupert'oo�Sesness License#:
1�A T � 5 5
Building Permit Info: �/
Bldg ❑ Elect Q Plumb M Mech EY
Job Description:
Residential Commercial ❑
,Cost of Project: n!�
Strapped On Platform Bonded
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
CITY OF CUPERTINO
I 2 of 2 PERMIT RECEIPT OPERATOR: euem
COPY # 3
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 36907008.00
DATE ISSUED. . . . . . . : 10/13/2005
RECEIPT #. . . . . . . . . : 31598
REFERENCE ID # . . . : 05100067
SITE ADDRESS . . . . . : 10191 VICKSBURG DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CABRAL GLENN L AND ANN T
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3318
RECEIVED FROM . . . . : AFFORDABLE WTR HTRS
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 SAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ENERGY 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
_________________ ------------ _________-_____--_
OTHER 168.04 MASTERCARD
TOTAL RECEIPT 168.04
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
__________________
502 FINAL PLUMBING ENERGY 506 - GAS TEST
507 FINAL PLUMBING
•