08060175 (2) CITY OF CUPERTINO ,r -<s x .ry :r SIS-.&s`�wb<R we '
BUILDING DIVISION PERMIT CONTRACTOR INFORMATIQN .;
..A rs «C ✓ .h:r�- �w
PERM T NO.
BUIt.41tic1q��cE�S. ESTATES DR AFFORDABLE WATER HEATERS & 08060175
OWNER'S NAME: PERMIT ISSUE DAIS
CHARLES E AND DORETTE I 24707 RAILROAD AVE 06/24/2008
SANITARY NO. CONTROL NO.
ARCHITELT/FNGINEER: BUILDING PERMIT INFO
REPLC 50 GAL WATER HEATER 'BLED ELECT Plume MECH
0 0 0 0
goo LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm that I am licensed under Provisions of Chapter 9(commencing P
== with Section 701111)of Division 3 of Ne Business and Prefinumns Code,and my l4ersm is
^=N infull fomeande teL
License I L"m.N
Dace Condacbr
ARCHITECTS DECLARATION
I mtdersand my plans shall he used ss public retards
gots Licensed Professional
3 OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from be Canuactoes License Law far the
00 fallowing mason.(Section 7031.5,Business and Professions Code:Any dry or county
3$T which mquirea a Permit to commun.alms,improve,demolish,or repir any suuerum
_Z< prior m its issuance.also requires the applicant forsech permit he file a signed stsmmem
E F O that he is licensed pursuant to the provisions of the Convector's leave Law(Chapin 9 Sq.Ft. Floor Area Valuation
�{ $ (commencing wird Secuan 70007 of Division 3 of the Business and Profemiov Code).,
S — Nat he Is internist rx^^from and one baso for the alleged exemption.Any violation of
Scotian 7031.5 by any applicant for a Permit subjects Nc applicant to a civil penalty of APN Number Occupancy Type
ret mare Nan five hundred dollar(3X07. P y yP
I,uowmr of rile property,mmy wplayw wird wageassdm'v sole eompewdon,
will do Newooss and Ne he Contractors
n)a ret s LMed or Law
dos s sante(pec.to s s maxima
vw property
wh ons Cade The Cont ereors License Law antra oat appy m an owms is Required Inspections
propertywhobuildsviimpmwachimpr andwho alassuchwart NmrJfed through his
owns employees,provided than suchimpm oldwit aremtinan fomoffered fm sok.IL
however,the building m improvement la mid within otic Year of mproe for the o is of
builder will haw the burden of proving that k did not build or improve far Puryose or
sale.).
❑1,ss owasr of Ne Propeny,am exclusively condoning with Bars mnuacmm to
construct the project(Sec.7044,Business not Professions Code:)The Cmentemrs U.
cave Law does not apply to an owner of property who builds or imporm themon,red.
who concocts for such pmjccu with a eon ractm(s)licensed pursuant to the ContractoA
Licence Law.
❑Iamaamptmder Sec .BAPCIm Nisseason
Owner
Data
WORKER'S COMPENSATION DECLARATION _
1 hereby alfrmuM r Ne ly or Kdury om of Ne following d IMOons:
I have sail will rami.•Cmtigcam of Canunt he elf-lnsme for Went's Compen-
swan,as provided for by Section 3700 of the labor Code,for Ne performance of do
work for which this permit is issued.
❑1 have and will malntaln Workers Compensation Insurance,as m9uimd by Section
3700 of the Labor Code.fm perfarmanee of the work for which this permit is issued. '
My Workefa ComPenss'mylyunnce artier and Poli number
Carrier.2li �Yl� Policy Na
CEKTUICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
musmsdm need not becmnpkted if Ne permit is(prom hundred dollars(3100)
nr leu)
I ccrufv,that in the performance of the work for which this permit is intend.1 shall not
employ anypermn in any mamrerso ss in Income subject in the Worker'Compevauon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL afar making this Certificate of Exemption,you should
become subject Le the Worker's Compensation previsions of the Labor Cnde,you moa
.J z forthwilh comply with such provivaro w this permit shall he deemed mmkW.
zO CONmucrLON LFNDINO AGENCY
'A I thereby affirm that them u a mMmctim lending
f� Ne work fur whichcirri 3 agency for the performance of
GQ Landers Namc pert"it la issucd(Sec.3(19'1,Civ.C.)
=Z Landers Address
U O 1 notify that 1 have road Nice application see stats that the above inform,um Is
IT, F come 1 agree a comply with all city and county ord roman and sum laws reading m -
.0 U building construction,and hereby authorim mpiescnauves of this city to enter upon the
shove-majored Property for rex co ertion purymea
(We)agree to save,indemnify and kap harmless the City of Cupertino against
vn h in
f thoSoso and expense which ma way ,acrncagalnstsaid City
U z in consequma of Ne granting of this
SOURICANT ULATIONS ND PLY ALL NON-POINT Issued by: Date
Re-roofs
mgnuum or onuacmr mm ./�
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant stmt or handle havrdoes material
ss dAimd by the Cuiscrom Municipal .Chapter 9.12 and the Health and Safety
Code.Sued.u532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Ya o
If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicant or future building by the B y A equipment or devices which P g
nit havardnus air contaminants ss do by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Nu
I haw reM Ne hvardonsmaterials rtquiroments unr4r Chapar6.95 of the Califor-
niaHmlN&Softly Coda Secuov25 .2557 am125534.I mdcnand lhatifNc building
duct ret murend an at it' mapor��rttbilis'rn fruits,de occupant of Ne
myulm ¢h mm t umEofcC 'k cup
� Signature of Applicant Dale
owmrmanthori ed,gcm DatAll roof coverings to be Class's¢'or better
CITY OF CUPERTINO
• 4 ITEMS OF 20 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . . 36907030 . 00
DATE ISSUED. . . . . . . : 06/24/2008
RECEIPT # . . . . . . . . . : BS000005201
REFERENCE ID # . . . : 08060175
SITE ADDRESS . . . . . : 10198 E ESTATES DR
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CHARLES E AND DORETTE I ACKERM
ADDRESS . . . . . . . . . . : 10198 E ESTATES DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014
RECEIVED FROM . . . . : EDDIE D NALLEY
CONTRACTOR . . . . . . . : LEONCE ROUX LIC # 26850
COMPANY . . . . . . . . . . : AFFORDABLE WATER HEATERS &
ADDRESS 24707 RAILROAD AVE
CITY/STATE/ZIP . . . : SANTA CLARITA, CA 91321
TELEPHONE (661) 259-7131
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 11900 . 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
ITRAVDOC 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
---------- --------------- ' --------------------
CREDIT CARD 532 . 80 MC
---------------
TOTAL RECEIPT 532 . 80
VOICE ID •DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER
•
a CITY OF CUPERTINO
WATER HEATER
of
• CUPEkTINO PERMIT APPLICATION FORM
APN # (P 9 7 c,) Date:
23fuir
Building Address:
IOIgg Es��+�s
Owner's Name: �" Phone #:
Charles =1(y�e/w��� q6r-7-zT. ?-07/
Contractor: Phone #: 717 /
Fax #: SSS
Cupertino Business License #: Contractor State License #:
2 (a 8S (� Z 7365'
Contact: Phone #:
� C y `,k I I I•e f-I Y� G (, I 2S5 —05- ZG
Fax #: G I 23-� e/]7L
Building Permit Info:
Bld ❑ Elect ❑ Plumb Mech ❑
Residential [� Commercial ❑
Job Description:
Strapped On Platform ❑ Bonded 17 New Location ❑ Replacement ❑
Valuation (cost of project): G U
Project Size: Express Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to
the application or if applicable, include in plan set & the sheet index.
Green Building Points achieved:
�Z
Revised 6/16/08
aCITY OF CUPERTINO
WATER HEATER
CITYOF
CUPERTINO PERMIT APPLICATION FORM •
Quantity Fee ID 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
r 1PPERMITFEE Plumbing Permit P
/ e
1TRAVDOC Travel & B
Documentation
1BUSLIC Business License B
•
Community Development
";. 10300 Torre Avenue
"�'' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
q�UPEI�TINO
Building Department
JOB ADDRESS: _
PERMIT #
oto6D _1 ?S
OWNER'S AME: ha✓) aJcjvm � PHONE #
GENERAL CONTRACTOR: ,,1.0-. J„ FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followin 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