06040050 (2) C C ITY OF CUPERTINO
BUILDING i)IVISION PERMITi�CONT"CTORINFORM,.A�ION.
u" -
ILDINGADDRESS: PLUMB IN TIME INC - P"Em"NO-06040050
22085 LINDA VTRTA PI.
OWNERS NAME: PERMIT ISSUE DATE
NEAR JAMES E AND NANCY T 360 MEMORIAL DR STE J40 n4/11 /2006
NE: SANITARY NO. CONTROL NO.
(866) 293-3031'
ARCHITECT/ENGINEER: 1 BUILDING PER .INFO
BLDG ELECT PLUMB MECH
O Oz
LICENSED CONTRACTOR'S DECLARATION
Wroby due 9(carearnmecog Job Description
w'dhS.La F "..7MAM) -fDfvi ill—3oflivellusincesseed ProrcisionsCadimenclatylicencesis,
in full force and affect. REPLACE HOT WATER HEATER/ 40 GAL GAS TALL 12YR
Liccome class c_-5�2 .. OcaR92�_&
"Oem
Dam---L�E�CHMCCI`E DEC
LARATION
c I uncontested my plans shill be used m public mends
)�u
ett; Licensed Prolmsional
I hereby
...OWNER-BUILDER DECLARATION
j 2 Nat I am excenp,from the Connurector',License Low for the
CiZo following mason.(Section 103 13,Bonsisom and Profeammar Code:My city or county
9 which caumm a Permit W construct,tied.improve.dorentim.Or ropeur any stram. $500
priar u)its iscumse,also requires the applicant for such permit to Us a signed statement
than be,is licensed pursommi W mo provisions,of that Connector's Liconses Law(Chapter 9 Sq.Ft.Floor Area Valuation
(contravening with Sestiort 7000)of Division 3 of ft Business and Prolkessim;Carta)or
Nat he It attempt therefrom and ft basis for Na alleged exemption.Any violation Of
Section 7031.5 by any applicant for a permit subjects ft applicant to a civil penalty of Occupancy Type
not mom game fivs hundred dollars(3500).
E]I.mowner oftie proNny.wmympioyamwed warm wNab salt wmpenudw,
wed Nd Profession Coda;T1m Cmuremours License Law doest ML Apply M au MM Of Aafttions
property who builds at
themon,and whodo%mchwarkithessellor through his w3c'
.employees.providead that such jorprovemmus m but imacradical orroffored ftermim If.
however.the building ar,imponscresem itsold within 0.year ofcomplatum.duc manam-
builder will how the market of proving that he did not build"Improv for ptupow of
sok.).
(_']1.as Owner of ders property.am excludycly contracting with licensed contractam;W
commen man pmjca(Sam.7044.Business real Profession Co&-,)The Comarecuses Ll- SIX ONG
ocress,Law does not apply as in answer of property who builds or improves theater.and.
who concracts for such projects with a comouster(s)licensed paressumi to den Contracton's
Llcmae Law.
[3 1 son merept under Set _'B&P C for this meamm
Ow. — us
Da
WORKERS COMPENSATION DECLARATION
I mumby affirm motor penalty of perjury rom a man following dwlarmorta
4t 1 ban and will maintain a Certificate of Consent to salr4muse,for Warkeres Compen.
mount..pat far by Section 3700 Of the Lab"Code.for Na per form eacc of the
work for whims this permit m itatual.
0 1 have and will maintain Workers Compensation Incomes,.required by Session
3700 of Na Lester Code.for the perficarmanot of chat work,fee which this permit is issued.
MyWorkce�MCITWn�.csaao.or and Policy number rom 2
Carrier. Policy No.: _`a1L? —
CERTIFICATE OF EXEMPTION FROM WORKERS*
COMPENSATION INSURANCE
(rhas seettirm reed mat N camplema tithes permit Is forrove hundred dollars($100)
or Im.)
I comity Onat I.to Itcurammence of the work I.which this pareal,is Wood I WWI notemploy any pentrun in my manners as w laccame,subject to the Worker'Co�apcmrmkm
Laws of Cedifmoia.Data
Applicant
NOTICE To APPLICANT:If.of mating this Certificate of Esemplion,you should
become abject to the Wormers Compensation provisions of the Labor C"'Is.You mm
0z forthwith comply with each prervisiom cer this permit!hall be damnedanooka
z 0
CONSTRUCTION LENDING AGENCY
1 hereby affirm Use theme Is a consuructiont lending agency for,ft purpormano,of
ai> the work for which this permit 4 imused(Sec.3097.Ch,C.)
Galander'.Nano
G.
Lender's Adidas,
U Q I certify dial I law read this Application and sum Na to show Informed.is
U,F connect.I agree to comply ints all city and county uncleanness and mile laws relating as
0 Ubuilding construction,and hereby autbGrice mpoeactomwa of this city to enter upon the
L4 chow-mentioned property for inspection purposes.
06 (We)a&.to saw.indemnify and lampInmennism uses,City of Cupertino Slibut
rad lis"i ties,judimmus,cam and expenses which may in my way accout against mid City
in consequence Of the Smand"I of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT Issued by: Date
SOURTE TIONS
_it_ Re-roofs
Signatme,of ApplicantfCanuninctor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Witt ma applicant.future Wilding actsupentsuare or handle laccurdous trammel
as defined by ft Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(!)? All roofs shall be inspected prior to any roofing material being installed.
El Yce To
Will the applicant or rulum building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
orch hamodaus fit murnaimants as defirmsi by thas Say Am Air Quality Management all new materials for inspection.
District?
0yes 1�<
Ihaw mad the hadm.amHalsmquim=nmun&rChapmr6.95ofdicCalifon
building
does not currently have a motors.th"It 4 my responsibility to mdr,the occupsom of des
reclal. ,muss be met priorte,Wartime ofa CernficamodOcculsomy. Signature of Applicant Date
—0
CO&
All roof coverings to be Class"B"or better
Owner ustint.d.di about Date
r Community Development
10300 Torre Avenue
J' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
WUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
2-1409z Lt,-,S Q b �o
OWNER'S NAME: J o lv-e s PHONE # 4(9,0 S' OD 'S-
GENERAL
GENERAL CONTRACTOR: Ve,�lo <` — c FAX #
I am not using any subcontractors: ^- Q- e
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 i l 2 7 Ce 0 7
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
• /
Owner/Contractor Signature Date
CITY OF CUPERTINO
46m 1 of 2 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35608014 . 00
DATE ISSUED. . . . . . . : 04/11/2006
RECEIPT # . . . . . . . . . : 33925
REFERENCE ID # . . . : 06040050
SITE ADDRESS . . . . . : 22085 LINDA VISTA PL
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : NEAR JAMES E' AND NANCY T
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4022
RECEIVED FROM . . . . : JASON SCHERR
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
*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
•
i
CITY OF CUPERTINO oUo4 0013c)
• WATER .HEATER
CUP kTINO PERMIT APPLICATION FORM
APN Date:
35 -08 - 011 - / II
Buildi g Address:
� fico �1
Owne 's Name: Phone#:
MW\Q� r
Contr ctor: License#:
Conta t: + Cupertino Business License #:
Buildi g Permit Info:
Bld I❑ Elect ❑ Plumb In Mech ❑
Job DIscription:
Resid tial Commercial ❑ �ler qC)
2 r'
Cost of Project:
00 ,00,
Strapp d ❑ On Platform Bonded
• New cation ❑ Replacement
Qty. if
A li able Fee ID Fee Description Fee Grou
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbin Permit Issuance PLUMBING
/ BENERGY Ener
USLIC BUILDING
BB
usiness License BUILDING
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