06120063 (2) CITY'OF CUPERTINO
BUILDING utvlslory
PER. CON RACTbC1RII'NF,OR tMATIOIV �_
BUILDING ADDRESS: AFFORDABLE WATER .HEATERS ERMIT NO. 06120063
7492 FALLENLEAF LA
OWNER'S NAME: PERMIT ISSUE DATE
DAN SMITH 24707 SAN FERNANDO RD 12/14/2006
E:
SANITARY NO, CONTROL NO,
(661).259-7131
ARCHITECTMNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
iO0 LICENSED CON RACTOR'S DECLARATION Ib Description
%wF I hnebY affirm Nn OeSCri 1 am licensed under provisions of Chapter 9(commencing P
1zU with Section 70100) fDi kion 3 or the Business and Pmressiom Code,and my license is
in fun macande Fm. ��73(e� REPLACE WATER HEATER
a�i License Class_ Lic.a
a,� Dale Cumrac or
ARCHITECTS DECLARATION
i e a 1 understand my plans shall Ire used as public records
)yU
o y
Licensed Pmfcssional _
g
OWNER-BUILDER DECLARATION
<f I hereby alTrm Out I am eaempl from the Contractor's License Lew for the
D O following notion.(Section 7031.5.Business and Professions Code:Any city or county
m which requires a permit to comssrvcl,.Iter,improve,demolish,Or spun any structure $1200
pniore,its issuance.alsn rcquircs the applicant rorsuch pumiuo rile asigned slatemcm
< that he islkcrucd pursuant to the provisions ofthe Commons License Law(Chapter 9 Sq.Ft.Floor Area Valuation
2!=-'� (commencing with Section 70)0)of Division 3ofthc Businessand Pmressions COdc)ur -
6 0 that he is exempt therefrom and the basis for the alleged exemption.Any violation of
section,7031.5 by any applicant for a permit mbjecu Ik applicant o a civil penalty of OccupancyType
not more Nam eve hundred dollars(5500), YP _
❑I,as Owner of the properly,or my employees with wages as their sole compensation,
will do One work and the structure is not intended or offered for sale(Sec.7044,Business
ant Prove siona Ci de:jbi conuactgr.License Law does not apply in an owner Orr
properly vWbldi or impiovuthemm.and who does such werkhmself or Borough his -�J�
own cmPloYLrs provided Wssuchimprovementsrt aos intended arolTered for aide.if }1�O
however, nve
the bolding ompromenus sold within ydrofcomplcuon she
r
Wilder willhave the louden of proving that he did not Wild or improve for purpose"A ---- -- - ••r R'.:I"?:O. --- -- ----�- -�
cele law does nota I to an owner of property h"builds or int Merton,and
0 property, Y gwr
Pr") apply D a Yw ) prose
I.is Wrier Of diedm L1C1YS1VLl COnVdcllm N1¢'tsed COmllaelOR b-.
' cotiridlA NC en(Sec.7044.Business and Profsrons Codc The Conmaor's Li.! � PEI:nJIT ISSV'nA'p:
who contracts far such projects wit a conlRctons)licensed pursuant to the Contractind
r'Lieiosi Law:--- "- - - e•NfLtT,'i NO. CONIRULKu.
r �1 vm cacmps under Sec. .B&P C for Nis rtazp,i
DwrrLr_ _ _.__— _--__— ______Dose_- _.--_.___ ____ — — _—_._______
- "rili frCItLNGWORKER'S COMPENSATION DECLARATION -^ ----_ ----- I3t;It,J!V'.i l+!i L:R RJO
Ihereby+femt under penally of perjury one or NL following declarations. EI LCI' Pl,lJrd" N=jiaralions: r
c+mand will maimaina Cenifintepf Canmhuo6elf-l.um Nr Workcl -- ----�----------J-�---- �--.--.---....�—�-- ----- -�----�-
:�o sCompcn ____
ration,.,provided panty Section 3700 ofthe tabor Cade:faLNe perfmmbm aLd,e X05 I i°SCi�itilr(1
work for which,uis prem L is Jssoud.1t.,Inru sed Profrrs:uus Cndc.amt Try Liccrv:ix
I' I-'.ce hn"d:q. 1
yI [7W ofi end orCoaimain Worker's Compensation Insurance,az his"uimd by Section
j MyW.Ne's Cm pansia9r Nsurancem icolllie work fn whir aro, pem,il is issued!
My WorkcYS Compe.atian tnsurence camiu and Peiigy,numkrart:'--
11 OJ
�'a Canieccac!"••�/tls k'{.f`'%r.ser,!as Polity Nit.i'1 / 0 / o -
...CERTIFICATEOFEXE MONFROM�WORKERS'---.— I
COMPENSATION INSURANCE
i'Si%r U!LLCN Ji:CIJ It A1:G`:
)Ci I 1(This section need not keompleted ink permit is feronc hundred dnllaa(SIUO) -
c."Smless.).:: rc.ISeui✓ 7W1.',,Bas -xs and I'roi.a ,a.rte:A.ry c!y ser eeumy �
O OTIC Nm n she p<'fn c f she work for which this e s s ucf I shall'
Ittn{f- Ir
p os __
c�ploy ypcsa0 In any on Me so as In We.sblect to Wo ktRC mpensatlon- 1
Q r 5 I•I F �orY t ' `daluaty ,
�e EtTOAYPLICANPrf seer makin thpie Ccnf spf r '
A ' 8 r, rmn shall k deemed
C l f a Guide
(ok"e mM1)ett'm the WDikcrs Compensate o p o s o s ohi vul c
`JCCIe'LnC':':Te
�O ToMwiN cont 1 wW¢bdh m an.or this ked • -
by ¢1 i. I ps 'n
---
r•L-frofl ksbY off am dot Vert Raco awn, lend ngaggncy fo fiePe furmam,cu _ ._- —_.- _ ._ .. . 72„<;rlU ILC Inl:pCr{,t1P: .. -.-
x thc,wurk fu h ch Nd,pemsu rs Iss ed(Sec.J(HT Ci -C) hi eI v,-o•gl hi;
y.f] IitWc(s Name ��i ati1 F'.4y : '�:� y .� . . .r•s� :+��:,
J p vl'�nF'ai cm fy th rl'12ive read Bo x apptieilion end salt Nil,6e abobe nfbtmdiiuu.ist -
Y p pe Y p pugwms.oleos Lrdul i` ' ,'
L F gr PY wI Y Y ting so
unn
= Ui ¢.•..(Wc)e6ma to pve,indemnif .d km hatmle.'.Ihe Cit of Cun nino ago lhci
c9rtcct. a ce m cam I Nall cit and count oNinences and slate Taws tela — - --
inst
uldm copsuvctp ,and hcsb autkri.m reunsauv.OfthOcl mL tau
site cm uoncd ro n-forms Lotion sLr I -- � t'rrt; s
Jh IlabrliuesJ dgrlmnls chsR antic pc a.which m.yrnanyway accrue egai at.b OtyJ (�/y-[�/�`/iy(/�, ///^/
Z 'n coni ANTI NDERSal gofN ipermiC .__ - - ._.. _.___. - _ . '-
APPLICANTr UNDER ANDS AND WILL 0 PLY WITH ALL NON-POINT
Issued b n�) �'r'Date I ' 6'
SOURCE ATI. . L Y _--_ _ -------
;M
._._.
y/oG
', ,
Re=roofs — —
S'g alY: AIy e r-MAZnu Dor - - Dale _
:1 y t3 .HAZARD0U5 MATERIALS DI5CLO5URE o c t ,x. Type of Roof +t' h•f'.
� - ed byte'Cupil Bic tr ftrcbuilding cpntaocorh handle Toth es teal - -- - -- -- - -- - - -- - �—
' .dcRricd by Ne Cupen no Mumnpif Codi Cnapmr 9.12!11id Ne%Heilih arid Safety' .r b 1 tri`LII 3r
Cedo co4m.1oi ne t
1 r �Ye,,t All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without y lm v r r c.a, h '.:'•r ,
first obtaining inspection,I agree to remove
)i Wtll,thc appl onto building oct p s use cggipm
morvc m hich'
fubrtg an P
u haAr ca consent,. tsaz Jcrncd by,lbe Bey AoaAir;Qmlly Managcmcnlr all new materials for inspection.
Cis...Ll ':•Ixrx s :�r, . .n..r, p
_ -a�Ycs
CLa
1f 1 _V
( "'rlha aced Nc harardtws re l limquisme use do Chaps fiail c Wildin-
I es OuBo&Sef tyCo"c Sccurns25fli f'i 33 and 255341 dusundN '"Nc bis ld ng
docs not c rrcmly h L Nat t s my pont b 11 ty i h Gly Nc a upanl of Nc' -
' rtq rt- h mu dp�orb cc of edaN of atop cy
'J tt h rt ,' I JV� Yah ,1 Signature of Applicant Date
P. ! I Ow oro uNor icd agent!I „ - 5,. r[. t ! ;All roof coverings to be Class"B'or
n...... t
t+;;•ylrt% n A.FiPx aq�'�hF ,,.,yT� mar .i. hl;�'-}.,r, °.n u,hawse!— _ _._ . . _ __.._ _______._�___ ._._ .__ .
Community Development
10300 Tone Avenue
,F Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
•CUPEI�TINO
Building De artment
JOB ADDRESS: PERMIT#
7 L 42- Fo) II,eN <«r L*9
OWNER'S NAME: T5f) -j Sn. ti PHONE #
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
SUBCONTRACTOR BUSINESS NAME BUSINE 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
z 1 a6
Owner/Contractor Signature Date
CITY OF CUPERTINO
06m 1 of 7 PERMIT RECEIPT OPERATOR: amyw
COPY # 3
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35928019 . 00
DATE ISSUED. . . . . . . : 12/14/2006
RECEIPT # . . . . . . . . . : 37051
REFERENCE ID # . . . : 0612'0063
SITE ADDRESS . . . . . : 7492 FALLENLEAF LA
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : DAN SMITH
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : AFFORDABLE WATER HT
CONTRACTOR . . . . . . . : LEONCE ROUX LIC # 26850
COMPANY . . . . . . . . . . : AFFORDABLE WATER HEATERS &
ADDRESS . . . . . . . . . . : 24107 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
---------- ------------- ---------- ---------- ---------- ----------- --- -------
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
•
CITY OF CUPERTINO
WATER HEATER
CITY Or
CU
PERTINO PERMIT APPLICATION FORM
APN# saq _ �� 0 Date:
Building Address: VlY
7` cl1 k- �a1(er12GF L �
Owner's Name: Phone#:
nfnn S . . 1 h qv�- a57 - 33 (r8
Contractor: Phone: License#:
abe arer -7131 (Oa-73be
Contact: Phone: 1pbf Cupertino Business License#:
coir U1rlet-;eld s D54
Building Permit Info:
Bldg ❑ Elect ❑ Plumb M Mech ❑
Job Description: (as)
RePIcACe SD o
yooe\ Wooer HukT2r (SQme ) BC0.T,9r1 = Gari e
Residential Commercial ❑
Cost of Project:
I
• Strapped ❑ On Platform ❑ Bonded
New Location ❑ Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BPVa-MATER Water Heater/Vent BUILDING
PPERWITEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
•