08040068 (2) CITY OF CUPERTINO
BUILDING Dy1SION PERMIT `yyA0
BUILD NO ADD FSS: PERMIT NO.
�
145� MILLARD LN FAST WATER HEATER 08040068
OWNER'S NAME: PEPMIT ISSUE DATE
KING NEIL C AND SILINE 12601 132 AVE NE 04/09/2008
NE: SANITARY NO. CONTROL NO.
ARCHITECTRSNOINBP.R: BUILDING PERMIT INFO
RMV/RPLC GAS WATER HEATER BLDG O PLUMB
l� O
.00 LICENSED CONTRACTOR'S DECLARATION MIOb Description
Mwith
ted 1 hereby affirm dui 1 un licensed under provisions of Chapter 9(Commencing
withSecdan 70f10)ofDividon Sof am Business and Professions Code,and my lice�tsu
^may in full fore underfoot.
2 L7 z License Class t.ie.{
Date Contractor
ARCHTIECI'S DECLARATION
I uMemand my pies shall W used u public meords
C
5 Licensed professional
b N
y OWNER-BUILDER frown" RATION
a I harthy eHirm that 11. exempt from the famous o 1:Any C Law for de
i p O whichfollowingre reason.(Section 7U31.5.Business and ere.de uv Code:Any city or only
$m which i am iresWo•peas,re Bores t,alter.hnprou,h pCmil t or e a sig ed abuotum
�, pow miu issuance,also requires the applicant for such Penniuo file ulgned sutemmt -
€< that he Is licensed purmanuathe provislonsofdteContractor's License Law(Chapter 9 Sq.Ft, Floor Area Valuation
8 (commencingwiNSeceon7000)nf DivWon3ofthe Busineomd Prtfcaaiov CcAe)w
�.. But he In exempt tharmho t and to basis for the Wleyed exemption.Any violauan of
Section 7031.5 by any applicant for a permit subjects the applicant is a civil penalty of APN Number - Occupancy Type
not mese dam an hundred dollars(165Dm.
0 1,a awunm of the property,w my mploru with ways a deb mu=pensadm,
will do the wary..and die muccuR 6 rum Intended waReRd far YW(Sec.70M.Boammods
red Plefcsdana Coder The Cantrmmrs License law does m1 apply m a^owner of Required Inspections
pmpenywMWilNwimp^ ChM .mdwhodoumchwkhimW[w WauNbu
own emplayoos,provided that such improvements an not be, woRcrtd forsalc U,
howenr,the building or improvement is mid within am year of aompktian.the aweer-
builder will have,the tMm of proving that M did Out build or imparme fpr purpose of
ate.).
0 1,as owner of to property.am exclusively contracting with Iimnaed mnwnws in
common the project(Sec 7044,Business and Profession.Cada:)The ContnmaYa Li-
mo law does not apply us an owner of Property who build.or Wind a themon,and,
who Conpacts for such projects with a c.modoar(s)licensed pursuant m the Contractors
Lkvua law.
0 lameaemptudder See .B&I'Crwdthreasnn
Oweer Data
WORKERS COMPENSA770N DECLARATION
I hereby affirm under peully of perjury nun of the following decluuionac ,
M.aM will msiow.•Certificate of Covent to self-Inmrt for Wortela Compeo-
nu provided for by Seoul.3700 of de labor CadW prmance
Cade,for eefaof de
or which this permit is issued,
0 1 have and will maintain Workers Compensation Insurmm.u mgdmd by Section
3700 of the labor Cade,for the porf.red.c.fum wort far which Nis permit is bound "
My Worker.Components.Inausanm carie and Policy number tee:
Conies PollcyNo.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thin atom need not Weampleted ifthe permit Is(wane hooded dollars(5108)
or beat)
T cmify that in the Mr....of the xarx for which this permit in issued.I shall nes
employ my person in my mnmter an an to become subject to the Warlmof Compmuadw
law.of Califamic Due
Applicant
NOTICE TO APPLICANT:If,after making this Cenilh a e of Exemption,you xMW
become subject in the workers Compenudon provisions of dm labor Cade,you most
Q O fonhwith comply with such Provisions or this Permit 0,11 M doomed routd
e
Z ti CONSTRUCTION LENDING AGENCY
[-+ Ihemby.lnmt But Vert iso Conswction lendingagency for the perfamanmuf
fYv i thc wort for which this Permit Is issued(Sur.3097,Ch.Q
W Q Lender's Name
z Lcn&esAddress
U Q i certify that l haw read this applimti^n and mute thus the above Information i.
ly^ comm 1 agree to Comply with all city and county mellowness and suss laws mladnp an
building consWnion,and hereby authors representatives of this city to toter upon the
W aMve-menuovd
M'..'Inspection pumdOCL
C (We)agree to sive,indemnity and keep harmbeu the City of Cupertino a{siv,
sy IA Imbllidm judymcnts.cow and expenses which may in my way incomeMaim,said City
in
C)
APPLICANT NT UNDERSTAmace of the NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Slynuurt o(ApplicaDOD Gam
HAZARDOUS MATE RIALS DISCLOSURE Type of Roof
Will do applicant m(Muni building Occupant
orcuPant amrt w handle Innuendoes material
ss de0vde d Cupertino Municipal Cadmil the c.Chapter 9.13, Health and Safetycafe.scctlon 25533(a)7
OYoa ON. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant,or future building occupant sic aqulled"I w dcvicv which If a roof is installed without first obtaining an inspection,.I agree to remove
I huAtdoes.1,cmtsminants as defieed by the Bay Ama Air Quality Managc...L all new materials for inspection.
ricR
❑Yea ON.
I ban mad the hnadws msterish requitemem s under Chapter 6.95 ofthe hlifor.
nit Neal"SafmyCadc Sctiw dter
25505.25533 and 3553/.l msurlJct de if building .
Janes not currently have a muni tins it h my responsibility to oddly the occupant of the
mgpimmentswhichmostWendpooranimmaneeofaCmnesteorampmaY. Signature ofApplieant Date
Owner or suthorimd agent Dam All roof coverings to be Class'n"or better
CITY OF CUPERTINO
• 4 ITEMS OF 24 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32644053 . 00
DATE ISSUED. . . . . . . : 04/09/2008
RECEIPT #. . . . . . . . . : BS000004429
REFERENCE ID # . . . : 08040068
SITE ADDRESS . . . . . : 21450 MILLARD LN
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : KING NEIL C AND SILINE
ADDRESS . . . . . . . . . . : 21450 MILLARD LN
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1300
RECEIVED FROM . . . . : JEFF JORDAN
CONTRACTOR . . . . . . . : JEFF JORDAN LIC # 29100
COMPANY . . . . . . . . . . : FAST WATER HEATER
ADDRESS 12601 132 AVE NE
CITY/STATE/ZIP . . . : KIRKLAND, WA 98034
TELEPHONE . . . . . . . . : (800) 454-8955
• FEE ID UNIT -- QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
--------- -------- --------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 449. 00 0. 50 0. 00 0.50 0 . 00
IPPERMITFE FLAT RATE - 1. 00 40.79 0. 00 40 .79 0. 00
1PRWHEATR UNITS 1. 00 24 .48 0. 00 24 .48 0 . 00
1TRAVDOC FLAT RATE 1. 00 40 .79 0. 00 40.79 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 106 .56 0. 00 106 . 56 0. 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER -
• c
Permit No: 080`/00 618 398520
(office use only)
City Of Cupertino Building Permit Application
• E-Mail: Building-Permits(Dcupertino.orcI (Address is case sensitive).
Jobsite Address:21450 MILLARD LN Date: 3/31/08
Assessors Parcel Number.
Owners Name: KING, NEIL Phone No: (406)736-5073
Project Valuation: 449.00
Building Permit Info: Bldg Elect Plumb x Mach
Job Description
Remove/Replace Gas Water Heater
Contractor Information
Company Name: FAST WATER HEATER COMPANY Phone No:
• Contact Name: Carol Randall Fax No: 800-454-8955
Address: 12601 132ND AVE NE E-mail: carolr@fastwaterheater.com
City, State & zip code: KIRKLAND, WA 98034
State Contractors Lic. No: 877469 Expiration Date: 5/31/08
Workers Comp No: 1761660 Expiration Date: 12/1/08
Carrier: California State Fund
City of Cupertino Business License No: 29100
Credit Card Information
Credit Card No: 4417123041349530 Expiration Date: 11/10
Name on Card: Jeff Jordan
Visa ® MasterCard ❑ American Express ❑
The Building permit application and a completed & signed
• contractor/subcontractor form need to be submitted with each permit.
q commanity Development
10300 Torre Avenue
' Cupertino CA 95014
Telephone(408)777-3228
0 Fmt(408)777-3333
• CUPEkTINO
Building De gent
JOB ADDRESS: 21450 MILLARD LN PERMIT#O0 O[7/ 06 (P 8
OWNER'S NAME: KING, NEIL PHONE# (408)736-5073
GENERAL CONTRACTOR:FAST WATER�H,E�AaTTEER COMPA FAX# 425-814-9516
I am not using any subcontractors:_ / d0is3/31/08
Signature Date
Please check applicable subcontractors and complete the'following information:
60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets&Millwork
CementFutishing
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
•