06120038 (2) CITY,OF CUPERTINO > -
BUILDING DIVISION PERMIT kCONTRACTOR INFORMATION`,
BUILDING ADDRESS: PLUMB IN TIME INC PERMITN0.06120038
OWNER'S NAME: - PERMTTL5-5UEOATE
WANG ROGER C AND SUSAN T E AL360 MEMORIAL DR STE 140 12/11/2006
IRV NE: SANITARY NO. CONTROL NO.
(866) 293-3031
ARCHITECT/ENGINEER: BUILDING PERMR INFO
BLDG ELECT PLUMB MECH
�Op LICENSED CONTRACTORS DECLARATION Job Description
ed FC I hemby affirm that I am licensed under provisions of Chapter 9(commencing P
�z wiOScetion7OM)ofDivision3ofN Buvrex NOCeuiaM Cade.and lianseu
in Tome aerreffectREPLACE WATER HEATER
;q= renandLicenseau Lir.g
t-� Dam Conuacm
eS rATIO
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undersand my pima shall W used as public recards
aU
a C Licenced Professional
5 OWNER-BUILDER DECLARATION
<I I hemhy affirm Jul I am exempt room tW Contractors License Law for the
p O Winningmoon.(Section 7(0 1.5,Baines"and Profession CoJc:Any city or county
fm which mquires a permit to c..L Ave..improw,dcamluh,or minor any swctum $500
'n prior m its issuance.also requires the applicant for such permit to Ole a signed sammcm
a< that hculiccnxJpursuamtothe proaJm
visioafConuacmr'sLicense Law(Chapter 9 Sq.Ft.Floor Area Valuation
'FC (commencing with Section 7000)of Division 3 of the Business and Profession Code)or
$ that W is exempt therefrom and the buss rm the alleged exemption.Any violation of
Section 7031.3 by any applicant for a permit subjects IW applicant to a civil penalty of
not mart than rave hundred dallus(M()0} [ Occupancy Type
❑1,as owner or the property,or my employees with wages as their sole compensation,
.41 do the wast and the anncto.is om muouled or Offered fmsale(Sec.70M,Business
and Profession Cade:The Canuactors License Law does not apply to an owner of Required Inspections
Property who Wildsorimpmms thereon,and wW daeswhwmk him self amluough his
awn employee,provided Nat such improvements ve mnimended oroRered forsam.B,
howevo,the building or improvement u to within one year of completion,the.-
builder will haw the burden of proving that he did Mt Wild or improv for purpose of
sale.).
❑h as owner of tha property.am exlustwly contracting with licensed cemme ors to
contract she pmj.a(Sec.7044.Business aM Pmfessioa Code:)The Conuac rte,U. _
cove law does not apply b an owner of property who Wilds or improws thereon.and
who contracts for such projects wish a commemr(s)licensed pureem,to Use Contractors Lice.law.
❑lomesempiunder See .B&PCforonismamn
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby of imnunder penalty of perjuryone of the folbwing dcclaranioa:
I haw and will..I dam a CcniOcam of Consent o self-insure for Workers Compen.
,Mo.,a MAded for by Section 37M of the IIWr Undo,for the lacrtchon to of the
work for which this permit is issued.
❑1 haw,and will maintain Workers Compensation Insurance,as mquimd by Seetion -
37M of the LaWr Code,for IW performance ofthe Powork for which this permit is isamd. '
My War s Compewuon Inas c mer 61- 1i nu bor
Carter cy N
SLf� a/.CMFICATEOF % MMONMOM WORKERS'
.L _ COMPENSATION INSURANCE
(Thu section need not W completed ifthe pere i,is forame hundred dollars(SIM)
or less) ..-._._
I comfy Not in the performance of the work for which this permit is issued.1 mall nut
employ any person in any manners,as to become subject m the Workers'Compenauon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this CCnIDem or ExemP0011,you should
become subject In Ne Wekeri Compcnxuon provision of tW labor Code.you most
.J z forthwith comply with such provision or this permit shall W deemed mwked.
Z'O CONSTRUCTION LENDING AGENCY
[r I hereby affirm that them is a construction lending agency for the performance of
6i tin mutt for which this permit is utted(Sce.3097,Civ,C.)
W� QLender's Name
] z Leaders Md.
C.3 Q i certify that I have mad this application and sate than the allow information is
!I. cenccL I agree 10 comply with all city and county aNiumms and state laws minting to
�U building conNuction.and hemby aulhorix mpresenutiws of this city to enter upon the
mew mentioned pmperty fur inspection purposes.
H 6W. (We)agree to save,indemnify and keep harmless she sty of Cupertino against
liabilitie,judbmenu.coaand exp,^•-•which Zmmlly yaceme against said City
J in camx nee of the printing of Nis permit.
'-' APPLI UNDERSTA AND WILL CO Y WITH ALL NON-POINT Issued by: Date
OU E ULA N -
gra ApplicanUCanuacun Cast, Re-roofs
FIALJtDOus MA DISCLOSURE Type of Roof / —
dldeappiicamarfuturebuilding ansate.or"Mi.Woodcn maaond
Us,defined by Ile Cupertino Municipal Cade.Chapter 9.12.and the Heahh and Safety
Coca.Secy.zsvxa>? All roofs shall be ins ected nor to an roofing material bei.
❑re Ne P P � Y g g installed.
Will thc applicant or future Wilding occupant Use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit havardna air contaminants 4 Jpfned by the Bay Am Air Quality Management all new materials for inspection.
Disuin? �/
[3Yes C]No -
I have toad the W>aNausmamrials requircmcmu under ChMmr6.95 ollhc Califor.
ria Health&Safety Code,Secuan 25505,25533 and 25534.1 understand hatiflAc Wilding
d Int curtsy haw a lenmc shat It u my msponsih'itY m notify the occupant s the
whiehtmatte m.ruiasaanee.n eu0emar van gnature of Applicant Date
wrm Narncdagcm D,m All roof coverings to be Class"B"or better
CITY OF CUPERTINO
2 of 2 PERMIT RECEIPT OPERATOR: bethe
COPY # 1
Sec: Twp: Rug: Sub: Elk: Lot:
APN . . . . . . . . : 32619092.00
DATE ISSUED. . . . . . . : 12/11/2006
RECEIPT #. . . . . . . . . : 37001
REFERENCE ID # . . . : 06120038
SITE ADDRESS . . . . . : 21900 GARDENVIEW LA
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : WANG ROGER C AND SUSAN T ET AL
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1132
RECEIVED FROM . . . . : PLUMB IN TIME
CONTRACTOR . . . . . . . : PAUL HENDRIXSON LIC # 27607
COMPANY . . . . . . . . . . : PLUMB IN TIME INC
ADDRESS . . . . . . . . . . : 360 MEMORIAL DR STE 140
CITY/STATE/ZIP . . . : CRYSTAL LAKE, IL 60014
TELEPHONE . . . . . . . . : (866) 293-3031
IRE 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
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ------------ _______-_-________
CHECK 168.04 2506
TOTAL RECEIPT 168.04
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
Community Development
4 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
4UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
6 5( (.._'In
OWNER'S NAME: PHONE # O�S 7_ -�r'L/ �F
GENERAL CONTRACTOR r FAX#
I am not using any subcontractors: Z2-
Signature Date
Please check applicable subcontractors ancom Tete the followinginformation:
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
CI'T'Y OF CUp_,pVVATER HEATER
�I1��
•
-PERMIT APPLI
-
APN 7
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Building Address: — —=—� _ Date:
Z)19M ( � '
Own Name- �Cr� U'1 Lh
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Conir4ctor: --. Phone#:
' �lofl 691. 513
Euildin Cu
g Permit Info: pertino
Business License #:
Bldg io Ei L4
Sob D'
ascription: Plumb 'N ;
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1 Rential j
1 Comedmeril C S(�
Cost oca
! Project: i
I
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Supped On Platform LTJ
' Bonded
New li cation
i — Rep;acemeai
Chy.l il'
linable Fee ID
BPWHEATER Fee Description
Heater/j
PPERMITFEE Water
' Vent Fee Grouo BENERGY Plurnbinb Perim tIssuance BUILG
m
13USI.IC Eney DINPLUMBING
Business License BUILDING
BUILDING
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