06020052 (2) CITY OF CUPERTINO
BUILMNG DIVISION
PERMIT
.........
BUILDING ADDRESS: AFFORDABLE WATER HEATERS SPERMITNO.06020OS2
10410 FLORA VISTA AVE
lerWSNAME PSRMrr ISSUE DATE
JUD'ITH CHANG 24707 SAN FERNANDO RD 02/09/2006
PHONE: SANITARY NO. CONTROL NO.
(661) 259-7131
ARCHO'ECTIENGINEER: BUILDING PBRMTTINFO
BLEG ELECT PLUMB MECH
z
LICENSED CONTRACTOR'S DECLARATION
Ibnbuyffina Main sm licensed under provisions of Chapatr9(commcning Job —sc-ii-ptidn
.3mi'MeSusirmstard!Proicuslons Code,and my licessfis is IALED
1 f litrult and IT REPLACE 75 GAL WATER
M w,M See fDvz
to on t e !?,-
Lt. vo Lot,
comuscour
n 1- _LARATION
i19 "R - - 2006
I understand my phosmall Im used AS public records
Licensed Professional
OWNER.BUILDER DECURXnON
I lococtry.fron that I am exempt from the Contrawtor's License Law for Me
7031.5.Business And Professions Code:my city or county
E a following modern.(S"fi BM" N"25
1§2 which ox,mind a pconstion slur.morromm.Mungih.. pal,Any domem. 1400
v` prior to its asmance.also requires the Applicant lor,wh permit in file a signed stancurnon
ti We W A licensed P.M..,in the proAmAts of ISO commerce.Lice.Low(Chapter 9 Sq.Ft.Floor Area Valuation
�10
(commencing with Section 701010)of Division 3 of thot Business and Profession,Code)m
Most W it muump,thamfrorni and the Saudis four iffics alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit Subjects the Applicant in a civil penalty of -5 APM Mnib�r U U Occupancy T�pe
Act..than fl.hundred dollars,D50(t).
o I.as owner or Me,property.A,my employees,with wages AS their wit compausation.
will out Me wad,and MA,sonscume is not Intended an offered for safe(See.7044.Business
and Professions Code:The Cornsfifiefor's License Law deces,not apply An in mooff of Required Inspections
property who build,orimprevocs tiverson,andwho dmzsmhwmk himselrorLthrough his
onvot employees.provided Am such Improvements the moinnended croffend!forsall If.
hathaver.the Wilding or improvencent Is mid within one year ofcompledon.Me owner.
builder will how Me burden of running MAI he did not Wild or borrow,for purpose of
ASIA.).
0 1.As ow.of the property,..exclusively contracting Ilh licensed cormacum,In
construct the pmjcci(Sec.70,14.Business and Professlons Code:)The Contractor's Li.
cense Law does not Apply to an Owner orproperywhot Wild,or Improves,Memon.and,
wins contracts for such projecta with a contruscusts)licensed pursuant M Met Contoomloes
1.1ccom LAw.
C3 I am attempt under Sec B At P C for this ressm.
r Dow
WORKER'S COMPHNS;MON—DECLARATION
I hereby Mm under penalty of perjury one of AS following declarations:
0 1 have and will maintain a Cenificame Of Commit in salf-WAS,for Woftes Compen-
sation,AS provided for by Section 37M of ths Labor Code,for Me performance of ft
work for which this permit Is issued.
(3 1 how And will maintain Worker's Compensation hosurance,AS required by Section
37M of the Later,Code.far AS perfoomance of We wric for which this permit is Issued.
My Worker's Camrsuisfition Insamance courier and Policy...her sm:
Caurs=-;;Pe#, CIA.— Policy No,
CEIrrIFICATEOF EXEMPTION FROM WOR ERB"
COMPENSA71ON INSURANCE
Crus socsion recd nott,ccompleutJ]film Permit 4 two=hundred dollars(SIM)
or W&)
I certify that in to performance of Me work for which this permit is issued.I shar Act
couploy any person In my manner an AS an becom abject in the Waft"'Compensation
Lows fCAM1..A.Dam
Applicant
NOTICE TO APPLICANT.If.After making this Certificate of Exemption,you should
bescon.Subject an Me�Vorkces Confrontation previsions of the Latour Code.you a=
z lonlonth comply with Such provisions;or this Permit Shall be dourned reversed.
z CONSTRUCTION LENDING AGENCY
I hurcloy affiren that ft.I...mustroacdon lending army for dific puffornmes of
> ft work for which Out permit is issucti(S.3077.Co,.C.)
Lemour.Nkence
Lentlee,Addrum
Z)z
U0 I CaudifY Man I have Rod this Application W SAM that ft move infAM8110fin is
commes.I atme in comply with all city andi county ordinances and sude Is" I.ti.1 to
C) buildiolconstruattion,and hemby,whodre ociponsfismadvc,of this city m Muct upon ft
menc-arentioned property for insixuction purpoems.
(We)agree to Save.indemnify and keep locomfiess ft City of Cupertino apim,
liabilities.judgments.costs and ex,ensfifics which May in My My NMAX APIASL Said city
U - "A' of 'n of"A permit.
T 0 22ATU AND N WILLCOMPLYWITH POINT
'A pp Issued by: Date
0 — _C7
AL, k 701. Re-roofs
Signtsurre of ApplicsoLACOninfificter Dow
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will ft Applicant or future building occurpart am or bandit himundous;material
defined by Me Culfillffin
Section 25532AP 0 Municipal Code.Chapter 9.12,mul Me Health And Safety All roofs shall be inspected prior to any roofing material being installed.
Oyer, 94C
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 contaminants AS M,fl.cd by the Sty Area Air Quality Management all new materials for inspection.
District?
El YLS
I have road Me hatardous materials requircmems underChapter 6.95 of the Califor.
rt�,:Ialthjk it -Soc�..MS05,25533md25534.lun&mtWthalfft Wilding
d th Lcnaffl, it my imnsibilltymn nonce. to
ot av I At met do, a Militate of Oct Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner or authorized agent Dam
aClOFFax
Community Development
Torre Avenue
Cpe0rtinoCA 95014
Telephone(408)777-3228
�PE�T�No (408)777-3333
Building Department
JOB ADDRESS: 1 0 y j u r1 LvrA vW „q PERMIT#
�-
OWNER'SNAME: L L.41)1PHONE # Lfo%-C6C1- LrZY S
GENERAL CONTRACTOR jjrpu et)nc3i ,a-r . a, s FAX # /
I am not using any subcontractors: 2 5 /6 6
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
It• 2 of 5 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 32628076.00
DATE ISSUED. . . . . . . : 02/09/2006
RECEIPT #. . . . . . . . . : 33152
REFERENCE ID # . . . : 06020052
SITE ADDRESS . . . . . : 10410 FLORA VISTA AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : JUDITH CHANG
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : EDDIE NALLEY
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 HAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
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 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
02/02/2006 07:48 66122599556 AFFORDABLE WATER HET PAGE 02/02
CITY OF CUPERTINO
• WATER HEATER _
CuR&JINO PERMIT .APPLICATION FORM 06 0 a X6 a
APN# Date: e,,l _,�7ti 4/
Building Address:
Il)y10 Florw V"5iA A-JC • Phone#:
Owner's Name: L4.7 f— R1 qjx 4 3
ud;s>^ wn
Contractor: Phone: (c(t t License#:
ab e a e�Te rs g.SI .113 1 tog-) 3 G8
Contact: Phone: bbl Cupertino Business License#:
con --I1TIeF'eld 5 e�av meso
Building Permit Info:
Bl ❑ Elect ❑ Plumb Mech ❑
Job Description:
Rev��c<e 75 atlon Wo,Ter 6(tAT4r CSQme Iet'grs"nn
Residential Coal ❑
Cost of Project.. 400
• Strapped On Platform Bonded
New Location ❑ R lace ment
Qty. if pee Description Fee Grou
A livable Fee ID Water Heater/Vent BUILDINGBPWIIEATER Plumum Permit Issuance PLUMBING
IT
PPBRMM BUILDING
BHNERGX Ener BUILDING
BUSLIC Business License
•