08040080 MY OF CLPERTIyO
BUILDING DIVISION PERMIT = -ONTRACTQR�INFURMATION' »'
`rh'_+ 4vt'tYO P IO
PERMITNO.
Bu1Lip11gp�gogesVICKSBURG DR AFFORDABLE WATER HEATERS & 08040080
OWNERS NAME: PERMIT LSUE DATE
LISA CROOKE 24707 SAN FERNANDO RD 04/11/2008
g; (661) 259-7131 SANITARY NO. CONTROL NO.
ARCHRECDPNGINEER: BURRING PERMIT INFO
BLDG ELECTPLUMB MECH
0 0 0 0
30j LICENSED CONTRACTOR'S DECLARATION
Job Description
rd�' I Santry afro Wal 1 am IR,nsM under provisions of Chapur 9(Commoncing P
with Section 70I10)caDivision3ofthe Bpeincessrd Profestlwu Code."my lice is RPLC 40GAL GAS WTR HTR, SME LOC, INTR CLOSET
^�❑n in full roux wa creel/
Gia Uc"a cl}r{ea - e Lk.a
0 Dem Y—�—Conusemr
[ RLIUDSCrSDECLARA
[ I understand my plasmall he used u public reeorda
g pea
Licensed Profrsdonsl
OWNER-BUILDER DECLARATION
CO> I hereby.(Sero that I1. exempt from the Gonion,Cc :Anyclaw for the
O 4 following mason.a(Section lin str Bud ser. rod Professions code:Any city or county
ctum
L which its in •Permit W Construct.titer,Wprovo,demolish,nes repair ed auuctvre
Sid^
prior an licensnce,altort to tha ft PMaSOSO for Such permit Wicensele A AW( amanCOLspar9 -
< Wukulkc�dpuswantioWcpmvivisiuofNcConuwmr'andProfeaonsCodmr9 Sq.Ft. Floor Area Valuation
�D 1700
g "imemin`wiWSerancen nd of Division of caxndem.An,
ImMm of
Sec io u exempt therefrom and am.perm for the aliened eumptim.Any l comm of
Sado dam by airy red dont far a permit wbjeeu dm applkuua a civil penalty of Number Occupancy Type
at roam run nw hundred eollSn(sloe). 3 6 914 003'.aC7 PJ' '
❑Luawiterof Ne promny.«mYwplaye.wW mg.uthc4 role eompenution,
ad do f"dom,,Co We he Comb um'sLim «a ,chem«at applyBudr a. Required Inspections
and property
wh Wild,Cade:The Canuumr. nd who law dons rot apply lf rt awmr of q P
manem whopr «impmwaihermn,andwho areaoth wart himutfml through h4
howemr.Man Wilding
proveh imProwwnuarenot intendedmoEesedf Ownif.
however.ata Wildingmimpiowmmt,that
he
onsYe.ofcompletion,IWowmr-
sal..a NR Nw the 4uden of proving th.t W old rot Wild m impmw(or purynse of
uk.)
0 1,as mvoa of the property an exdusiwly canuaaing with licensed ce mmums to
mnsuun the project(Sc.7014,Business tad Professions Cade:)TW Cornua tura Li-
ccue Law dons not apply W an owner of pmpenY who Wilds or Improver Wemon.rod,
wW cam us lcumch projects with s mnuactorM ikensed Formai W US,ContwroM1 ,
Lircme law.
O l atn.emm und.See .B AS P C for thin maws
Own. Dam
WORKER'S COMPENSATION DECLARATION
I Wreby of irmunder peaty of perjury om of We fallowing declare io s
1 haw and will mainwn.CeniOote ofc...,an self-Iuwe for WarteYa Compce,
matian,as provided for by Section 3700 of We Labor Cade.for the performance of We
work fro which this permit is ruuM.
Q I law rod will maintain Wallace,Compem adon Imerwce,u ragWred by Section
370D of the labor Cada,f«We performance of the wart for which this permit is ipeud.
My Worsen's Compensation Inwnuo cavi.and Policy another art: p
Carder. -&L"+1', Policy No.: 1D67QSp�U
CERTIFICATE OF MEMPDON MOM WORKERS'
COMPENSATION INSURANCE
rn4 seetim peed Out he completed if the Permit Is for om hundred dollen(t 100)
or kis)
1 wdfy that In the mrrarm.nce a We work for which this Permit is brand.l mall not
employ any pawn in my mumrw as W become subject an the Wurtcra'Compemadon
Laws of Catifomia.Dam
Applicant
NOTICE TO APPLICANT:If.Sf tr madal this Ccrtifr.m of Exemption,you Should
become Subject W the Workces Compensation provisions of W lahm Code,you man
.,O forthwith Comply with asu h movidaor thin Permit Nall W deemed revoked.
„zCONSTRUCTION LENDING AGENCY
SZI
[-+ I hereby xlfirm that them is a construction lending agency for We Performance of
CYi> 0m work for which this permit is Wood(Sec.7097,Civ.C.)
W 0 Lcndees Name
�
z Lt Mees Adds,
U O I Comfy that I have mad this APPlicuran and nam this ate.Ww infarmNen u
(y E timet I agree be comply with all city rod county Mainanas and mum lam mining W
.� Wilding construction,rod hereby wthodm representatives of this city menter upon the
[i7 aWw-mendoad property for inspection pugWses
(We)agrce W aro,indemnify rod keep harmkr the City of Cupedino Sidon
Iiabiiiamjmgmmu,eovawdupepe.whichmayinuymy..Mimtrid City
U`l in consequence of We twang 0(this Permit
r� APPLICANT UNDERSTANDS AND W COMPLY WITH ALL NON-POINT Issued by: Date ��t✓a-'^
SOURCE REGULATIONS. //
Re-roofs
Signstum OtAplicangContractor D.te
RA2A
XA2ARDOU MATERIALS olsao 1u dI Type Of Roof
Will titeapplicant m future Municipal Code,
Coing e,Chapter
heuNansmatedai
u de0nnd by tiro CupeNm MuniciWl Code.Chapter 9.11.and tiie H.IW rod Safety
Code.Scotian]1]]1(07 All roofs shall be inspected prior to any roofing material being installed.
[3 Y. TIN,
Will the appliwt or future building acvpanl use egWpmmt or deviaa which If a roof is installed without first obtaining an inspection,.1 agree to remove
it hauNom air comma inwu as dc0md by the Bay Am.Air Quality M...scmcnr all new materials for inspection.
Dtsuinl
❑Yea ANO
Ihave moyC.d S.cd `mamrWarequimmmuunder CMpmra.9fofde Glding / ,Q q-11 —08-
rias nat. .gly las .Safi«u255itbm77u wli.l.n (ydthnifdc Wilding // I.�
da.rot curwtlY N a Iceme that It u my rnponsiNliry W maty tiro aecupwt a(dm '
requimmcnu which m Wmet pd�`W irmnaar.c.ariram araxnPaay. Signatur of Applicant Date
-` y-l/ D y- All roof coverings to be Class'"or better
Owner«aw maepem Dam'
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36914003 .00
DATE ISSUED. . . . . : . : 04/11/2008
RECEIPT # . . . . . . . . . : BS000004447
REFERENCE ID # . . . : 08040080
SITE ADDRESS . . . . . : 10336 VICKSBURG DR
SUBDIVISION .. . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : LISA CROOKE
ADDRESS . . . . . . . . . . : 10336 VICKSBURG DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3320
RECEIVED FROM . . . . : AFFORDABLE WATER
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, 700. 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
1TRAVD0C FLAT RATE 1. 00 40 .79 0. 00 40.79 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 106 .56 0. 00 106 .56 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 106 . 56 #3513
---------------
TOTAL RECEIPT 106 . 56
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
----- ------------------ --- -------- ----------------------------
518 WATER HEATER
• ��b�oo�b
1 CITY OF CUPERTINO
CCG WATER HEATER
CITY OF
• CUPERTINO PERMIT APPLICATION FORM
APN # Date:
L (oa i qoo �.�
Building Address:
10 3 3 (0 V UcS 1,urJc Dr .
Owner's Name: Phone #:
Li Sh Cr DD Ke YOE- 91L/Ll
Contractor: Phone #: 60- 151 - 7 1 3 1
Affordable Wader l�2aferS
Fax # : 661 - �Sy - 9ss6
Cupertino Business License #: Contractor State License #:
16 riSo 6�-'73��
Contact: Phone #: (,41 - a.s9_ 0 5d-d
Scott Litfilefielcl
Fax #: labl -�5�- 9SSb
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Residential �] Commercial ❑
Job Description:
�e� IGeA y� o�A��c� Sas wtik� {-IeA-Her- - ��me locc,tiuh : Z,.re��'o�
C
Strapped �] On Platform ❑ Bonded New Location ❑ Replacement
P
Valuation: I -700
Green Building Check must be completed and attached to this application.
Green Building Points achieved:
aCF
CITY OF CUPERTINO
WATER HEATER
CUERINO PERMIT APPLICATION FORM
Quantity Fee TD Fee Description Fee Permit Type
Group
1PCWHEATR Commercial Water B PCWHEATR
HeaterNent
1BSEISMICOM Seismic Commercial B
1PRWHEATR Residential Water B PRWHEATR
HeaterNent
/ 1BSEISMICRE Seismic Residential B
1PPERMITFEE Plumbing Permit P
1TRAVDOC Travel & B
Documentation
1BUSLIC Business License B
CITY OF CUPERTINO
' WATER HEATER
CUPEIZTINO PERMIT APPLICATION FORM •
APN # Date:
Building Address:
Owner's Name: Phone #:
Contractor: Phone #:
Fax #:
Cupertino Business License #: Contractor State License #:
Contact: Phone #:
Fax #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Residential ❑ Commercial ❑
Job Description:
Strapped ❑ On Platform ❑ Bonded ❑ New Location ❑ Replacement ❑
Valuation:
Green Building Check must be completed and attached to this application.
Green Building Points achieved:
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
*UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
10336 nr. GAO YaO ::f-<Z>
OWNER'S NAME: Li5A Cr-00K-4— PHONE # yop-JSa- ��Ny
GENERAL CONTRACTOR: FAX#
I am not using any subcontractors: C�� (- ) 1 - 08-
Signature Date
Please check applicable subcontractors and complete the following information:
60 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
• �/ - //- OSS
Owner ntractor Signature Date