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06030167 (2) CITY OT CUPERTINO t«°a *�,"', BUILDING DIVISION PERMIT ACONTltACT®R INi .OR OLiMATJOI01� BUILDING ADDRESS: PERMIT NO. 21589 EDWARD WY R'S NAME: PERMITL4UEDATE JIM LA FRANCHISE 970 E. MAIN ST, SUITE 200 03/29/2006 PHONE: SANITARY NO. CONTROL NO. (800) 835-5946 ARCHITECDENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 boa LICENSED CONTRACTOR'S DECLARATION Job Descri , ■� 1Wrcby goof that 1emftim Bounder provisionsPfuofCMper9(commencing N �� with Sotiton]Ofp)tof Division Sof the Busiraas IProfeaslo CN m liccn 4 �n in full fmaand[frn � (o y .WATER HEATER Lkease Cl v . Da¢ ITEC1-SDECLARATION C t� 1 understood h nd my puns dull usedu public recordsMAY 7-- 2006 5t; Licensed Professional .3 OWNER-BUILDER DECLARATION BUIL , B��(sy,� .�a I I hereby mOnm Nn 1 1. ,Bumps from the r Gtonpn"tort Liana Gw for the U e{V�j ep o following moon. emtiun 71131.ru Business and ver,dctiuli Code:My oily or County (] $tai which requires s permit.cnnstrveL elan improve,demoluh.m rcpasr any Iwcmm poor In is Issuance,ala requimsthe applicant forsueh Permit o file a signed statement < that he is licensed puruanlmthe provisions ofthoContioctur'sUccnselaw(Chapter 9 Sq.Ft. Floor Area Valuation r�g (commencing with Section 7000)of Division Sof Ne Business and Pmr".ions CMLe)ar Q — that be is exempt th"efrom and the hub for the alleged exemption.My Actedon of "AA71 nn Section 7031.5 by any applicant for a permit subjects the applicant to.civil penalty Of APR N-Liffiber Occupancy Type not roam Nan Bw hundred dollus($500). ❑1.As.."of the property or myempldyeu with wages As their anacompenastion, will do the work.and the mu"art Its not immmded or Offered f"We(SIL.7044,Business and Poorest] Code:The Comescmr's License Law does not apply N an owner or Required Inspections property w no builds or improves thermn,and who dos ouch wort hs,W f or through his ownemploy es,provided that each improvements ser mttn2mled oroRertd for ease U. however,Ne Wilding or improvement is sold within am year of Compaam.Ila owmr- builder will have the burden of proving Out W did nm build or improve for purpose of ask.). ❑1,As owner or de property.am exclusively contracting with licensed mnlncars in Consumer the project(Sec.7014,Business;and Professions Code:)The Conlncmis Lf- cane law does not apply b an towner of property who Wilds or Improves th"Con.and who Contracts for such projects wits a eonmemor(q Ilomad pun ant u tk Conlracmre Li,m m Law. I A.exempt under See .B&PC for this mason :r Dat WORKERS COMPENSATION DECLARATION I hereby affirm under penalty of perjury am of the following declarations: ❑I Morand will maintain aCeNrimmof Cowntuelf-imumf"Wo esCanpen- sa0on,As provided for by section 3700 of the Labor Code,for use performance of tie work for which this permit is issued. I71 have and will maintain Workers Compensation Insurance,u required by Scetio 00 of the labor Code.for the Performance order work for which Na permit is issued. My Workers. Compeas#n lnsunmx carrier and Policy nu r�:—�� Policy No.: RTIFICA�irnON FROM WORKERS' COMPENSATION INSURANCE (Thb sombre coed not W completed if tui permit Isforr m hundred dollar($100) ser la.) I Certify that In the performance of the work for which this permit Is Issued.I Nall not employ any person in any mannerso As An become subject to the Worker'Compensation Laws of California.Data Applicant NOTICE TO APPLICANT:IL after making this Certificate or EamPtion,you should become subject to the Worker.Compensation provisions of Ne LAWr Code,you must .JO forthwith Comply with each prevision or Ns NW permit all deemed revoked. Z r 0 CONSTRUCTION LENDING AGENCY E Ihareby 1111.Nn siert b a Conurectim Leading agency for der perfurmamx of E the work for which this permit is issued(Sm.3097,Civ.C.) QLand o s Name , u7. z lenders Address V Q I certify Nu 1 have read this application and sate that the aWw infmmatiun is p i F coned.1 as=to comply with all city and county ordinances and We laws muting in Q C.) building Construction,and hereby authorie representatives of this city to enter upon flue t1t ahove-mentioned property for impaction purposes. (We)agree to ave,indemnify and keep harmless the City of Cupertino Against ..�fain liabilities,judgments,coats and expenses which may inany way acme against said City U 7 in consequence of the granting of this pc I. F7 APPLICANT UN RSTAND A LL CO Y WITH ALL NON-POINT Issued by: Date �• Zai'—ri G SOURCE REG O �� Slgnutorca Appli"nUGntrsm" 3Re-roofs HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will Ne.ppliox t or future Wilding occupant mm,or studio Want..material OFBrad by One Cupertino Municipal Code.Chapter 9.13.and tui Health and Safety Section 25532(.)7 ❑Y" gy� All roofs shall be inspected prior to any roofing material being installed: Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air conuminamf as defined by No Bay Area Air Quality Management all new materials for inspection. District? ❑Yes I havc.W the huardous mamials requirements under Chapter 6.95 of Rte Califon- .is Health B SafetyCodc,Sections 25505,35533 and 25534,I undersand thus Vat Wilding doe not curtnntly how g tenant Net It b my rcapensihility a notify tui m[upanl of the require Is hich must m" w isau f a Cc 'Mas of fkcupanc W pa Signature of Applicant Date OA < rat Daa All roof coverings to be Class"B"or better • CITY OF CUPERTINO Item 1 of 3 PERMIT RECEIPT OPERATOR: suem COPY # 3 Sec: Twp: Rng: Sub: Elk: Lot: APN . . . . . . . . : 35619007.00 DATE ISSUED. . . . . . . : 03/29/2006 RECEIPT #. . . . . . . . . : 33787 REFERENCE ID # . . . : 06030167 SITE ADDRESS . . . . . : 21589 EDWARD WY SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : JIM LA FRANCHISE ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4764 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 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 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 acFax(408)777-3333 OPERTINO Building De artment JOB ADDRESS: aS S 9 Edjvm,4 � 0--j PERNIIT# a 603 m OWNER'S NAME: _tyh PHONE # '446 — 37 ( GENERAL CONTRACTOR. " IFAX# p I am not using any subcontractors: .9e, V"4 -1;1(( Signature T— 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 WATER HEATER (�30/(0� CUPEkTINO PERMIT APPLICATION FORM APN# 3 Date: Building Address: ;;L t S-e `1 �� Owner's Name: � y Phone#: 4 q-6 -3 7 6 $ Contractor;,.. Ph ne: License#: 9L� ?W S-591A 3 -744S -73 Contact: Q Phone: _ Cupertino Business Lense#: Building Permit Info: a/ Bldg ❑ Elect ❑ Plumb Mech '❑ Job Description: d� -A 2 !� Residential Commercial El a a�.> Cost of Project: �qa r -D Strapped El On Platform El Bonded El New Location ❑ Replacement Qty. if Applicable Fee ID Fee Description Fee Group BPWHEATER Water Heater/Vent BUILDING I PPERMITFEE Plumbing Permit Issuance PLUMBING BENERGY Energy BUILDING BUSLIC Business License BUILDING •