06060172 (2) CITY OF CUPERTINO x a,:ye V,c ¢ » " 'll, ' ' ' " :
BUILDING DIVISION PERMIT lCL)NTt C�,' ,%N�`f11WAIT N
BUILDING ADDRESS: , P N TIME ,INC PEKMITN0.06060172
21845 HYANNISPORT DR
OWNER'S NAME: PERMIT ISSUE DATE
EILEEN ROBERSON 360 MEMORIAL DR STE 140 2006
NE: SANITARY NO. CONTROL NO.
(866) 293-3031
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I� I�
u00 LICENSED CONTRACTOR'S DECLARATION IObDescription
UI hereby afarm Net 1 am licensed under provisions of Chapter 9(commencing
vnlh S"don7")of Di on 3afthe Bushmm.Wu f C Ikenxla
+ „ throimtiamerrea K� 3REPLACE HOT WATER HEATER 40 GAL GAS
j$Z Wcenx Oqlm Lk.N
CTI k-� Dam_In�ARCH
contractor-
[)am
ITECTS DECLARATION
D J!U I undersized my Plans shall W anti u public retards
c Licensed herebProny onsl
`y5 OWNER-BUILDER DECLARATION `'
COC 1 Wmhy atm that 1 1. memPt from dee Cantracton'sCut :Any c Law for the
COC fallowing won.permit
t 7831.5,Business and on.de oil Calc:Any m or county $500
$
which acquires issuance.permit w it ima t e eller.hnpmvu,dpconit. fi mash any alumurt
—Zi pat haor issensedPalx requires the applicant Of ficathrs"hpamit Uousele a LAW(Chtemem
F o deaWialiamdpuwantlaNepmvisumooftheDucme'fUanxlaw(Gapuu9 Sq.Ft. Floor Area Valuation
a�$ (commemingwihscction 7000)af Divbion7af the Bueinm and Profusions Cods)or
y Nat he is attempt detref ors and the basis far the alkged exemption.Any violation of
Sedco 7031.5 by any applicant for a pemtu,dbieae the appe.sat we ciml pushy of Occupancy Type
nut more than 8w hundred dollars(5500).
❑I,uownso(ttiaproperty.amyemploymwithwag$uthebxka pemdon,
will do the work and the immune is mtbsended"alfartd Waste,(Sm.70044.Burimusa Required Inspections
Nd RafeWOm Calls:The CumeacYf LIC$IJw dm.1 apply m N owner a( 9 P
propnywW builds orimpraws thereon.andwhodmeuch work hhoulf"oumgh his
am employees-provided that each imptosemtmta are not intended oroRemd for da If.
however.the building"imprommenl U said within arc you of eempktim.ate owmr-
builden wW have the harden of proving that he did rot build or Wpaw for purpose of
ala.).
❑I.u awmr of the property,w tichminly contracting wide flamed wntractaa W
cnnstman the project(Sec 7044.Burlttm and Politicians Coal The Cmttactors U.
came law dm eat apply w an oma of psoPstY rW Wilds or hnprorti dwrean,avd,
who mnmcu f"such projects wide.emmuse m(s)licensed intimater to Ne Contrxwh
License LAW.
❑lamexemplundersu. ,Bk PC(arthbroume
Owner Data
WORKERS COMPENSATION DECLARATION
I hereby,affirm under penalty of perjury oro of the fallowing declared=
1 have arta WHI mamal.a Csufimw of Consent to self-imrt f"warltmesCompcn-
sation,u powdd fa by Sedan 3700 of dee lab"Code,far Ne Performance a(the
wart for which this permit is fatted.
❑1 have and will maintain Worka'e Compensation insurance.u required by Statim
3700 of the laWrCade.for Ne peRarmarta of the work for which Nis permit b luded.
MyW aCryppyuu'Pn Inurance caoiu aml Policy num
/�(�t«yL Poliry No.:
�Ny� ���GERnFlG7EOFEKEMPrIN FRO 0
Tv �/�S- PE TIG I,t+ .
mtb sedan sed not W rompktd if Ne permit la("oro hunaeC dollua(SI00)
or len)
I artily Net in the performance a tW work per which this permit is issued,I"I ran
employ any person in any mamearan At to become subject to the Worlmn'Compenaem
Laws of California,Date
Appumat
NOTICE TO APPUCANT.It.after making NO Cenfficate of Eaemp mm,you should
became whim w the Workers Compemdm provisions of the Lah r Code,you mew
.70 roMwith comply with such provisions or this permit shall W clamed mooted.
zty CONSTRUCTION LENDING AGENCY
[—t I hereby afiim that Nem is amnurucdm lending agency for the perfomana of
ai the work for which this permit is Mand(Sea.3097.CN.C.)
LO LenWrs Name
7 Z LemicesAdd. .
U Q I attify that 1 haw rad this application and saw that Ne aWw information b
U,F correct.l agree to comply wide all city and county ordinances and ante laws relating w
0U building construction,and hereby authorim mpaxntatime of this city to enter upon the
{7.1 aWw-memiuned pmperty for inspection Purpura
i2t (We)agree to taw,indcmni(y and keep hors lm tire City of Cupertino agaiut
ata t;n liabilities.judgments.costs ad as..a which may in any way a.against aidCity
U in^ A connce of The Zranfing of LI�m UNDERSTANDS, D WILL COMPLY WITH L NON-POINTIssued by: Date
Re-roofs
ignst m BmnUCanmcwr Data
HAZARDOUS MATERIALS D CLOSURE Type of Roof
IBa applicantar forum Wilding cccupan
,(CLOSURE
land"hamduu material
u defined by the Cupertino Municipal e.Chapter 9.12,and dee Health and Safety
Code,Sudan 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ym
Will the applkent or future build! apart use equipment or dcvim which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air cmtaminams. dhythe Bay Area Air Quality ManaScmcm all new materials for inspection.
District
❑Yu Co<
I hive mal the hxzadom materials tequirtmcna underChepmr 6.95 of the Califon
nla Fkal kSafall, eI Sec6m25505,25533wW25534,lunde�d Nml(Ne Wilding
dm turnery how awas t It is my remomihllity,w notify the occupant of It!
M mems which mum t 'a tolssu cnirwa r rye, f//_ Signature of Applicant Date
Own urauthamcdagcnt Dow All roof coverings to be Class nBn or better
• CITY OF CUPERTINO
�m 1 of 3 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35613047 . 00
DATE ISSUED. . . . . . . : 06/19/2006
RECEIPT # . . . . . . . . . : 34931
REFERENCE ID # . . . : 06060172
SITE ADDRESS . . . . . : 21845 HYANNISPORT DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : EILEEN ROBERSON
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
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
�EE 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
CITY OF Fax(408)777-3333
OUPEkTINO
Building De artment
JOB ADDRESS: 2 PERMIT # O6G
. O 4 co I
OWNER'S NAME: PHONE # '
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
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
NP 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 Signa Date
j (Iev303 d�ap 3Srf4yr{1S
CITY OF CUPERTINO 00(00'172—
c, r WATERHEATER
• CUP kTINO PERMIT APPLICATION FORM
APN
Date:
Buildig Address: D�
"Al ' S an \ 5 0
Owne, s Name:
(%�fr Phone#:
a Co X108
Contractor. l
. License#:
Contact: 5z c, q
61"L
Cupertino Business License #:
��Q(?C if�ia!b+C� �(4
Buildi e Permit Info. ` / --
Bldg j❑ Elect ❑ Plumb.,
Job Description: Mech ❑
r
Resid 'ntial ' \ ' L O ca
Commercialkj
❑
Cost oProject:
I � OO •C'�O
Strappl dL.j On Platform Bonded
• Ll—
New LI cation ❑ Re lacement
Qty. if
A li able Fee ID
/ BPWHEATER Fee Description Fee Grou
/ PPERMITFEE Water Heater/Vent BUILDING
PlumbingPermit Issuance
BENERGPLUMBINGY Ener y
BUSL'IC Business License BUILDING
— BUILDING
I
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