06040055 (2) CITYOFCUPERTINO
BUILDING DIVISION PERMITtrURt�kC TNFURM.�."CIpN.�'f
i¢ a Wx3, sAF•,y x ., ri"h -S` .. e
BUILDING ADDRESS: - WATER HEATERS ONLY 1R11 NO,06040055
OWNER'S NAME: - PERMIT ISSUE DATE
CLAIRE SULLIVAN70 E. MAIN ST' STITTE, 200 04/11 /2009
NE: ISANITARY NO. CONTROL NO.
(800) 835-5946
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
E= 0 0 0
ioo LICENSED CONTRACTOR'S DECLARATION Job DeSCrIpI100
4 V 1 hereby affirm Nal I am licensed under provisions of Chapter 9(commencing
wiht Section 7009)ofDivWo.3 of the Business and Pro( um Code,and my license is
+ Bmilfameand&13(,v 37 '457 WATER HEATER �/
? Licenac a Llm.N
Dalme D, n lE
e^^E� ARCHITE
e y� 1 urmdcrsmnd my plans shall W use u public records
)EU
e W t; licensed Professional // �(/
y3 OWNER-BUILDER DECLARATION ANY /I/' `sv006
i 2 1 hereby affirm LintLintI am exempt from the Conlranors License law for we V
p o following mason.(Sweden 703 I.S.Business and Professions Cade:My city a county
5$ff which requires a permit to comma,alma Wprow,demolish.or repair any suuclum 950
-i�, prior In its Wounce,also requires the applicant forsuch permit to film a signed smument
<j that he u licensed pursuant in me prevision of the CaWactal Ucomc Law(Chapter 9 Sq.Ft.Floor Ar Valuation
ag (commencing with Section 7M)of Division 3 of the Business and Prowsman Cuts)or
tit
the,he B attempt th raftem and to basis far we alleged umnpton.My Noladon of
Section 7031.5 by any applicant for a permit subjects the applicant to•Civil penalty or i, Occupancy Type
ant more man five hundred dollars($.500).
❑I'm owner of Ne property,err my employees was wages u weir sok Compesation.
will do thewark and mesuumme B notimended ar offered forme(Sec.7(t14,Businms Required Inspections
and Profinetons Cade:The Contractors Utmost:Law dw not apply to as owner of q P
property who builds or improves women,and who dw such work him self a through his
Own employees.provided that such improwmus art not immmdol oraRsned for sale U.
however,the Wilding Or improvement B sold Wwin one year of completion.the owmer-
budder will have due burden of proving that he did an Wild or Improve for purpose of
sale.).
❑I.u owner of the prepeny,am exclusively commuting with licensed conasctom on
cautmct the project(Sec.7044,Business and Professiam Cade)The Comtracurs U.
cense Law does not apply to an owner of property who Wilds or hnprewa thereon.and.
who comnow for such projects with a conuaner(a)licensed pursuant to due Conmemes
LtrAme LAW,
❑Iamesemptunda See ,B&PCI'wwisminum
Owner Data
WORKERS COMPENSATION DECLARATION
I busby saint under penalty at perjury ane of to fallowing declarations:
1 have and will mainuin aCeeulicemof Consent w self-imm for WarkeesCompen-
tian,u provided for by Seedon 3100 of the Labor Code,fa the performance of the
work for which this permit is unsnarl.
❑1 have and will mintele Workers Compensation Insurance.as required by Section
37W ofthe Lata Code.for the performance of Um wart fur which this permit is lusted. '
My Wor�ye+ham C u me nimfuLa,nccc000am d Policy number a¢: o -
CarderlW //r icyNo.: qSd 3 -04 1
CE Fl ATE OF EXEMPDON FROM WORKERS'
COMPENSATION INSURANCE
(IhB seaim ceN notocamPletN If the Permit B faane hunNW do0en($1001
or Ing)
I cenify that in d e performance of we wmt far which this Permit is Wad.l small oro
employ anypemon in soy mama,.as to became subject to lM Worker'Cwmpa maim
laws of California.Dam
ApPlicurt
NOTICE TO APPLICANT:If,ener making this Certificate of Eaccepima.you would
become mbjm to ww Warta'a Campenudan provisions of the LAhm Code,you am
0 O
pi forthwith comply with such provisions a this Permit mil W dare
rned eked.
C7 CONSTRUCTION LENDING AGENCY
(- I hereby aRres used them B a construction lending agency for da performance of
a the work for which this Permit if issued(Sat.3097.Civ.C.)
GQ Lenders Name -
.7 z Lenders Address
U Q I cemify that I Iran read what application W sum dust we above information is
U4 F cormcw 1 agree to comply wit all city and county ordinances am sera Buss relating to
OU Wilding construction.and hereby auduame representatives of this city to enter upon we
GU move-mentioned properly for inspection purposes-
(We)agree to ave,indemnify and kap hannass the City a(Cupertino agimt
U
o sA Iiabiiides.judgments.toss aexpenses which may in any way amus against said City
U Z in eantequeue of the granting of this Permit.
r, APPLICANT UN ERSTANDS AND ILL COMPLY WITH ALL N N-P INT Issued by: Date
SOURCE REG O'NS,, �' D
Sb4A A. C.Gp rr f I G Re-roofs
Signarurt#7 AppliaMCaunemr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tst appliam or future Wilding accvpantpart ahandk haardous matron
at defined by the Cupertino Municipal Cade.Chapter 9.11.W live Halve and Safely
code. y.ssmz(eD ONO OAll roofs shall be inspected prior to any roofing material being installed.
Yes
Will thus applicant or inure Wilding ampant use cquipmcot a devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hanrdou air cone aiusm a de0ned by the Bay Arm Nr Quality Maugcmem all new materials for inspection.
District?
❑Yes ONO
I have read the hasardousmatenaB rtquimnamsundcrCMpar G9f of he Califs.
nBHesIw9 SafclyCade,seNau 25105.35533 and25534.1 unuk'rwvm wnifwe Wilding
dw not tummy haw a amen,that it B my mspmmbilily to netify to occupant of due
rcyairemcwwnicn maRW melpi m iauuxaara fcniraaa err Signature of Applicant Date
t)b All roof coverings to be Class"B"or better
0I Dam
J
CITY OF CUPERTINO
1 of 2 PERMIT RECEIPT OPERATOR: suem
COPY # 2
I
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32619140.00
DATE ISSUED. . . . . . . : 04/11/2006
RECEIPT #. . . . . . . . . : 33929
REFERENCE ID # . . . : 06040055
SITE ADDRESS . . . . . : 21910 EATON PLACE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CLAIRE SULLIVAN
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : BONITA JENKINS
CONTRACTOR . . . . . . . : MCGEE, PAT LIC # 18986
COMPANY . . . . . . . . . . : WATER HEATERS ONLY
ADDRESS . . . . . . . . . . : 970 E. MAIN ST, SUITE 200
CITY/STATE/ZIP . . . : GRASS VALLEY, CA 95945
TELEPHONE . . . . . . . . : (800) 835-5946
4EE 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
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
502 FINAL PLUMBING ENERGY 506 .GAS TEST
507 FINAL PLUMBING
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
SJPEkTINO
Building De artment
JOB ADDRESS: 9I a �t PERMTT# 0
OWNER'S NAME: C —tc-�cn PHONE # a- S S — /
GENERAL CONTRACTOR ,Q FAX#�
I am not using any subcontractors: ur 4 /4j&.. LpsdA�
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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor'Signature Date
CITY OF CUPERTINO
•CWATER HEATER
UP kTINO PERMIT APPLICATION FORM a�°yeas
APN# 3o� / Date: e f /!/Q
Z 6
Building Address: 2-1 91 O J J
Owner's Name:�n /� L Phone#:
Contractor: Ph ne: License#:
?c)c) 6,35—S91/6 3 7 y S '7 3
Contact: Q Phone: JCupertino Business License#:
I F 9?L
Building Permit Info:
Bldg ❑ Elect ®i Plumb Mech .1]'
Job Description: /Q y- K q /)
Residential 0Commercial ❑
Cost of Project:
5O
Strapped On Platform El Bonded
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
I PPERMITFEE Plumbing Permit Issuance PLUMBING
I BENERGY Energy BUILDING
BUSLIC Business License BUILDING
• I