04070163 (2) 7777
CITY OECUPERTINO ' "` �" $" � � •M77 7BUILDPERMITT�ij ' ' 'BDILDINGAWATER HEATERS & MORE PLBG. PERMIT"4070163
0920 CTOWNER'S NAPERMITISrUEDATEGERCKEL 1163 CHESS DONE: SANITARY NO. CONTROU 440.(650) 522-9287
BUILDING PERMIT INFO
ARCHI]ECT( BLDG ELECT PLUMBMECH
0 0 0 0
_oo LICENSED CONTRACTOR'S DECLARATION IobDescription
x 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
n< with Section 701XI at Division Sof the Bushon.,nd Pmfessiov Code,and my license is
< infallfmaanderzm REPLACE WATER HEATER.
_ License Clasm Lie-al
Z—o Dam Cannoneer
/s
ARCHITECTS DECLARATION
I undcss and my plans shall he used M public recarda a
Od�
;WtUi Licensed Professional JUL
X01
OWNER-BUILDER DECLARATION 3p 2004
i 9 1 W by affirm that I aro excmps from On Connector's License Law for the
i p O following mown.(Smile.AD 1.5,Business and Professions Code:Any city or county
a�Q which random a Permit to comonct,alcor,improve,demolish,or repair any structure
into in its issuance.alw requires applicant f.rsuch Permit in Bla eaignetl statement Vag �n
H r< that h is IlansoJ Pursuamto the Pmvisians of the C-nuuwr's Lkense law(ChaPrer9 Sq.Ft. Floor Area
rct (commencing wish Section 70010)of Division 3 of On lixonMaand Professions Cade)ar
3.. that he u exempt thawfrom and On bub far Ne alleged exemptive.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicwt to a civil penalty of
not more man five hundred dollen($500). be Occupancy Type
❑I,M owner of the property.or my employees with wages as their wk compensation,
will da the work,and the smuctore is not intended or offered for age 7044.Business 'Re uired Inspections
and Professions Code:The Conaurces Lianw Law dans not apply to w owner of q p
property who buildsorimpraws themen.andwhodonssueh warkhimwlforrhroughhis
own employees,provided that such improvements arc mKimmmded woffered forme.If.
,hurnmea me building.,improvement is sold within ane year of wmpledon,me-weer-
builder will have the bmdea of proving sen he did not build w improve for purpose of
sal-)
Z1,M owner of me propany.am exclusively antreeting with Ilo meed canaamon to
orderthe project(Sec.706x.Bustru ss and Professions Code:)The Contactors Li.
carne law does ma apply to an umn,of property wino builds or improved;toucan.sed,
who camases for such projects with ac-nuuWr(s)licensed pursuant to the Contractor's
Lim us Law.
❑I can exempt undo See. &P C f this reason
A
Ow I gUare(nAJJ
WORKER'S COMPENSATION DECLAR
I hammy aRrm under p malty of perjury one of the fallowing decimations:
I have and will maintain a CeNfiinumof Cement to self-imam for WorkarsCompen-
sation,M provided for by Section 3700 of the labor Cade,for me Performance of the
work for which this permit is seemed.
❑1 ban and will maintain Worker's Compensation Immomm,a required by Semon
]700 of the Labor Code,for the performance of the Omsk forwhlch this permit is Wand.
My wotkce,Campenwtia t Insmaae anise and polity mother am:
Cartier. Policy No.: -
CERTIFICATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
(Thin section need not be completed if the Permit is return hundred da Ilan($101)
Or less)
1 certify that in On perf rmanee of On work for which this Permit is issued,i shall not
employ any parson in any manners.M to become ant-el t.me Wwkms'ComPenMtim'
Um of CaRfmom.Dam
Applicaat
NOTICE TO APPLICANT.If,after making rob Ccntftcam of Exemption,you should
became subject to Ne Workers Compensation provisions of the lahor Code,you most
Q O forthwith comply wit such provisions or this Permit that be deemed revoked.
Z"" CONSTRUCTION LENDING AGENCY
E.s o-4+ Thereby in.mat shoo is a camomcdnn landing agency for Be performance of _
[�> me work for which thin permit is issued(Sec.3097,Civ.C.)
Is1 Q Lcnderb Name
o-7 z Lander's Address
U Q I certify that 1 have rad this applie don end sum Out the he.information is
IL F coronet,lag=to comply with sell city and county aminames and sats laws¢Ming in
QU building e)agree to saw,
aumasiareprcsomics,tof this city tocnmrupon the
U above-mantiowd propany for inspection purposes
G (We)-sae m ave,indemnify sed kap hay in an the City of Cupertino against
�4 IlehilidM,judgments.costs and expense which may in any way acerae against said City
U Z in commmume of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NbWPOINT Issued by:
SOURCE REGULATION I [ O
nay_' �_ � _�_ Re-roofs
91 ruren�han✓C.mtacm, m
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will to applicant or fulum building occupant stare or handle haarLaus material
M defined by the Cupertino Municipal Cade.Chapter 9.13,and the Health and Safety
c.&,Sauer.35532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes )/Wer
Will the applicant w future building occupant use equipment or dcvicett which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air cone ninwts M defined by me Bay Amo Air Quality Management all new materials for inspection.
District?
�YCS �U
I love mad me Wardens materials requirements under Chpmr 6.95 of thc Califon
nix Health&SafetyChda,Samoans 25505,25533 and 25534.1 understand half the building
does not currently haw a moan mat it is my resp-nsibility,0 notify the accupwt Of she
M airemcom which at ext mtlp' totuuwce of Cert) am Df Om.Pancy. Signature of Applicant Date
wncrmauthonudagwt new All roof coverings to be Class eBe or better
Community Development
10300 Torre Avenue
✓' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT
O 2 are �-vCKY OA K S7. ® U 3
OWNER'S NAME:Gx it NEV 7 �3 f —
GENERAL CONTRACTOR e,, e r e 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
• 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
WATER HEATER C,;) q `'�o G�
CUPEkTINO PERMIT APPLICATION FORM
APN# S h / Lo Date: D
Buildin Address: mm
10 b a
Owner's Name: Phone#:
Contractor: Phone: License#:
fe ,o re Z 29-9r-8
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb P5 Mech ❑
Job Description:
aac e
ResiJ Commercial ❑
Cost of Project: `0 59
Strapped ❑ On Platform El Bonded
New Location ElReplacement
Qt . if
A li le Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
CITY OF CUPERTINO
�m 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 32657003 . 00
DATE ISSUED. . . . . . . : 07/26/2004
RECEIPT #. . . . . . . . . : 26448
REFERENCE ID # . . . : 04070163
SITE ADDRESS . . . . . : 10920 LUCKY OAK CT
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER GERALDINE DUNCKEL
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-0126
RECEIVED FROM . . . . : GERRY DUNCKEL
CONTRACTOR . . . . . . . : LIC # 00004
COMPANY WATER HEATERS & MORE PLBG.
ADDRESS . . . . . . . . . . : 1163 CHESS DRIVE, SUITE K
CITY/STATE/ZIP . . . : FOSTER, CA 94404
TELEPHONE (650) 522-9287
OF TELEPHONE
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
----------------- ------------ ------------------
OTHER 84 . 02 M/C
TOTAL RECEIPT 84 . 02
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING