06050114 (2) CITY OF CUPERTINO > ra�
BY.ILDING DIVISION PERMIT " NrRACTCRN� ` M ' Ia
BUILDING ADDRESS: r TOM' S PLUMBING Pa""fITNO'06050114
20691 MC CLELLAN RD
OWNER'S NAME: PERMIT ISSUE DATE
gillk UPLINGER WILLIAM G 12246 SARATOGA S 05/12/2006
E: SANITARY NO. CONTROL NO.
(408) 867-6010
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
10o LICENSED CONTRACTOR'S DECLARATION JDb Description
1 is I bercby afRm dd,I m hennaed under provision of Chapter 9(commencing
Nwith Section 701)of Division 3 of Ne Businarad Profession Code.rend my license is
inmBfineeandarc�t_•Z f _ L� a i• / REPLACE WATER- HEATER
inn— Ucene Class 755
a1 Dom Cou ragge
Mma
ARCIIHIECIS DECD 0
l I understand my plan[hall M used w public roods �alSa� p
Licensed PnfeuknM ({(NpNJr},'`,��� �y`��{,�t$1
M �®
.s OWNER-BUILDER DECLARATION
iii I hereby.(Bre on I un taupe ,an Pr Conuarora License taw far the
0 o whichfollowing mann.(Satan T o str Buannt,and Profednn Cade:Any city s county
oolum
$ prim its is u a permit re ennsweL Sime impmw,demalm t m e a sig any urmmm ) $1150
iy pnveitaiensedpalso numntorequires IN thovisios o for Cchpermum Omstot w(ed ummcnt
�< (hat he is comeccenwit pSection hark)pm vision of do ConuamraUaneiaw(C ode)or Sq.Ft.Floor Area
aluation
$ thammendny with ecedr m and tof he bash
NS Business and Proon.Any
Code)or
Nu k k attempt1.5 btherefrom and due heels it Ota alleged redemption.to Any violation of
Sedan deed by hu applicant for a permit abjccu the applicant m•civil penalty of eTLg
�pe
set mart than Ow hundmE delWa(f500).
❑I.aewnrefthepsopeM.armywploymwithmrAnthe4amcompenadon,'
cid dolhewvk end theauctomlacoesLice Law does
Out apply In an,Brsimar Required Inspections
and property
h he Cade The Conhecm/m Lkxnse 4w uch set apply m rt owner is q p
propertywasebuBdomed nma thereon,andwho dmsuchworthimselfv Uuaughh.
ow aym,provided and such net is mid wait aro set intended moffesmpicho.for sale.U,
budderhowever.Ne building orimprowmnntg old a did ort eadyeara compass far de ownv-
huBM will haw tk burden of proving that he did set bWm er improv[m purpose of
tale.).
❑1,as owner of the property.sm exclusively contracting with Boned mnuacton to
construct the project(See.7044.Business and Profession Code:)The Contratars U-
caxe taw dm not apply m an owner of property who builds or impmvv theroa.and.
who conuacm for such projects with a conuactar(4)11^"sed pumunt to the Contractors
License law.
0lame naptunderSee .B&PCfarthisomen
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby a)Im under penalty of perjury one of the fallowing dedso uon:
I its.am war malntein a cadBats of catmnt to xlf-Iname far women.compen-
ati0n,as provided for by Secure 3700 of the tabor Cade,for the performance of W
work for which this permit is bound.
❑1 have and will maintain Worker's Compensation Wuranm•as required by Section
3700 of the Inbar Cade,for the perfammusax of the wort for which this permit is issued. '
My Workers Compensation Insurance artier and Policy number am:
Carrier. '/mie -h moi- rx-C--Peaky,No.: PIS I /%I
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE s
rants sections nand Out be completed If tae permit Is foram hundred dollars(Sip)
or Lae)
1 certify dust in the performance of the work for which this permit is issued.I"I not
employ anypersan in my manes o m become abject to the Workers'Compcwtion
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.a(mr making this ceniRam of Exemption,you should
become subject to than Workers Compewtion provision of the labor Code.you mtW
.J7 O forthwith comply with such provisions or this permit shall be deemed mwked.
.7y CONSTRUCTION LENDING AGENCY
H (hereby a(Rrm that dem is a connotation lending agency for the performance of
a 7 the work for which this permit is issued(Sec.3097.Civ.C.)
W 12 Lambert,Name
A. Landers Address
U Q I cerdfy that I have read this application and sate th+t the above information Is
tL I~ corwcI-1 agree to comply with all city and county ordinances and stm laws reading m
QU building construction,and hereby euthoda representatives of this city to enter upon the
r W above-asenuooses
ncd property for inspection purp
(~LL (Wc)agree to ave,indemnify ad tap hamlw the Ci of Cupertino against
rr rT Oabilitica,judgmems,cnso and expcnsn which may in my way seems against said City
U'Z in consequence of the grating of this pcmlt. 6 C
^" APPLICANT UNDERSTANDS AND WI L COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULLfIONS. S1 C—�
t1.rw N� Re-roofs ]�-
Si mai Ap icanVConmcmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant or forum building oceupatsam or handle hawdon material
as deMeed by the Cupertino Municipal Cade.Chapmr 9.12.and Oe Health ad Safety
Cade.Scotian 35532(4)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yrs 41
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
cash haardnn air comearmanta as deuced by due Bay Area Air Quality MangostuR all new materials for inspection.
OisuimT
❑Yes Rhin
1 have maJ the hazardous materials requiremene under Chapter 6.95 of the Califor-
da notcur Safety Cede SzJon 23305.25333 am bil4.i to soar tthis Rthemofft
Jana set currently hew•enam,that it 4 MY msponsihility m wufy the oaupent of due
requirements which mus he met zw bouaoafa Rcm of Occupancy. Signature Of Applicant Date
S7 2 All roof coverings to be Class"B"or better
Lowmar o4sthodrsustipun Dam
Community Development
e. 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
*UPE(�TINO
Building Department
JOB ADDRESS: p PERMIT#
'Zo e L cw 1 O 6dso// `7
OWNER'S NAME: W l QD r PHONE # o 1 f
GENERAL CONTRACTOR FAX # '113 2 1
T s PL�� U 'd-iq
I am not using any subcontractors'— o –o _04.t kl
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
)nA TV-,
Owner/Contractor Signature Date
CITY OF CUPERTINO
am 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 3
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35916010 . 00
DATE ISSUED. . . . . . . : 05/12/2006
RECEIPT # . . . . . . . . . : 34386
REFERENCE ID # . . . : 06050114
SITE ADDRESS . . . . . : 20691 MC CLELLAN RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : UPLINGER WILLIAM G
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : JOSEPH CLARKE
CONTRACTOR . . . . . . . : CLARKE, JOSEPH M. LIC # 10044
COMPANY . . . . . . . . . . : TOM' S PLUMBING
ADDRESS . . . . . . . . . . : 12246 SARATOGA SUNNYVAL RD
CITY/STATE/ZIP . . . : SARATOGA, CA 95070
TELEPHONE . . . . . . . . : (408) 867-6010
4kEE 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 VISA
TOTAL RECEIPT 84 . 02
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
-------- ---------------------------- -------- ----------------------------
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
CITY OF CUPERTINO 9050 11 '1
1 al WATER HEATER
• OF
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
3 � - 10
Buildin A(7ddress:
bq1 YhcClp(/a+ �d
Owner's Name: Phone#:
W. \i 157, `? t11
Contrac, or:msPhone: License#:
l e ' Ply �, ' gb 01 o
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect Plumb ® Mech [�
Job Description:
(&CR w [�
Residential Commercial ❑
Cost of Project: 1--
Strapped On Platform Bonded
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
•