08060174 (2) CITY OF CUPERTINO a h ".'g.g�,( ,t nr ' �t�y<g� Yy3a�ik (y `
BUILDINCbIViSION' PERMIT CO4�g.l�['iTQA��`jf�rOTIv,
BUIL1 PFAMn`NO.
Rg�TTICHWOOD DR AFFORDABLE WATER HEATERS & 08060174
OWNER'S NAME: PERMIT ISSUE DATE
MELTON DAVID O TRUSTEE 24707 RAILROAD AVE 06/24/2008
NE:
SANITARY NO. CONTROL NO.
A0.CHnECr/ENGINEER: BUILDING PERMIT INFO
REPLC WTR HEATER 40 GAL GAS BLDG EIECr PLUMB MECH
0 0 0 0
u p LICENSED CONTRACTOR'S DECLARATION - Ib Description
1 bemby Warm NGOesCrlPat I am licensed under provisions of
aMmr 9(commencing
with Section)010)of Division Sof the Business and Prafeuiuns Code my license is
in full forte an6eff
j�= License lass L— Lk.k
f p Dax Comrxur
QQ 7W RCHnECPS DECLARATION'
2< 1 und.aand my plans Asti be used as Public records
1,
a
u. Licensed Professional
_raOWNER-BUILDER DECLARATION
if 1 kmhy alrirm that I am Attempt from the Conlncto's License Law for the
i.e o following reams.(Section ROIs.Business and Profusions Cao:Any city or county
T which tarot.A Permit to canduuq alar,impove,dion.imh,ar repair any swmure
Zy Iuior in its issuance,sho,require the applicant for such permit so file A signed Mumma,
< that he is licensed pursuant to to provisions of the Contractor's License Law(chapter 9 Sq.Ft.Floor Area Valuation
Yt�-s (commencing with Section 7M)of Division Sof the Business and Professions Code)or
Nn he is exempt Nemfr°m and the bee for me Alleged uemption.Any violation of
section 1031.5 by airy applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mean man live hundred dollars(11500). P Y YP
I,uow.s of me pnhptny,.my wplayw wird waguudev r.4 cmnpeuation,
will do me work and theswclum is notimmrWod or offered tarsale(Sec.1DU,Buiness
,red ProfnsessioCade:The Conuxm s L erne Law clean but apply k An on.of Required Inspections
property who Wildsorimprowesmemmn,and whodoessuchwork himsclforthrough his
own smployce,provided mahmch improvements art not imm .offered for We If,
however.the bunking or improvement is sold within one year of compkdon.the owner.
builder will have the burden of Moving that he did not Wild or improve for purpose of
sale.).
❑1,As owner of the property.Am exclusively contracting wim Ile ou-0 wnummn to
want=the pmjm(Sec.1014.Business and Rofestions Cade)Tie Canuackrs Li.
cons,law does not Apply to an owner of property who Wilds or improves demon,and
who contracts for sixth projects with A contramor(s)licensed pursuant x the contractors
Licrnm law.
❑Tom exemptuM.Sec ,BB PC far mu moon
Ow.a Dam
WORKERS COMPENSATION DECLARATION
I hereby affirm uMer proudly of perjury ore million following declaralimu:
1 hfi A and will maintain a CaNBcam of Covent in self-inure fa WorkersCompen-
.it..At Provided f.by Section 3100 of the Lab.Code.for the p af.mance of the
work for whim this Mmhit is issued.
❑1 have and will maintain Workers Compensation Insurance,As required by Section
31(0 of the labor Coda for the performance of the work for which this permit is issued. '
My Wmrkee,Compensation ori.and Policy muu nbberr Ara
Grier. /GN Policy N°.:_W0,RK , r
CERnFlCATE OF SAnON INS FRAM WORKERS'
COMPENSATION INSURANCE
MTh xebec teed not W complcmd ifthe Permit is foram,hundred dollars(Sip)
or leu)
I eareify that in the performance of the work for which this permit is bound,1 shall not
employ any Person in try mans m As in become subject in the Workcre Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this CcrtiDum of Exemption,you should
become subject to me Worker"Compensation provisions of me Labor Cede,you muss
0z forthwith comply wim such Marble.or this permit.mall W dcemmid rewMd.
z O CONSTRUCTION LENDING AGENCY
[ti I Wrchyafiirm that mem iso covtocti°n lending agency for f Mcrfmmerec of
C> me work for whim cos Permit 1.iss.W(Sec.3091,civ.C.)
W� Ij Lenders Name
a z tinders Add.
V Q 1 certify that I have read this application and state mat tiro above information 1, -
Fcorrect 1 At.x emmply with all city and only aN1nY1LV and alalr laws rtladng in
.0 U Wilding construction,and hereby autherim representatives of this city to color upon the
[I.1 above-mwtionW property Inc inspection purposes
H LL
(We)agree to cove,indemnify and keep harmless Om Ciry or .gionino against
lir to in..iue.)udgmcnu.cnsu and expenses whit in any way awruc against said City
(„)z in eonsequenro of the gran' /A 'l
ti. APPLICANT UN AN A I COMPLY WITH ALN I DINT Issued by: Date
soURCER O
® Re-roofs
Signature dnmcor Data
r
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will t e applicant.future Wilding aceupantrore a handle havardons maloriW
As dcOnad by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
c«4,o an 25532s)? No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant sax equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
ih haurdons air contaminants u doth by 1W Bay Amo Air Quality Management all new materials for inspection.
Diu en
❑Yes e
I have rein the h+sardws manna n�mwuumler Chaplorti.95ofthe Glifa.
ria Hcil"SafelyCWe.Seed. 3 514.1 mWerund ren B the Wilding
�hnet c (N r p°vibilitY onotify m,occupant or the
n mmc°` ptr °tri°` es aCartrr"'h °"' Signature of Applicant Date
All roof coverings to be Class'W'or better
Owner or ans
uthasd agent Dow-
CITY OF CUPERTINO
• 4 ITEMS OF 20 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 36908045 . 00
DATE ISSUED. . . . . . . : 06/24/2008
RECEIPT # . . . . . . . . . : BS000005201
REFERENCE ID # . . . : 08060174
SITE ADDRESS . . . . . : 10253 RICHWOOD DR
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER MELTON DAVID 0 TRUSTEE
ADDRESS 10253 RICHWOOD DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3360
RECEIVED FROM . . . . : EDDIE D NALLEY
CONTRACTOR . . . . . . . : LEONCE ROUX LIC # 26850
COMPANY AFFORDABLE WATER HEATERS &
ADDRESS . . . . . . . . . . : 24707 RAILROAD AVE
CITY/STATE/ZIP . . . : SANTA CLARITA, CA 91321
TELEPHONE (661) 259-7131
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 1, 700 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1PPERMITFE 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 •
•
CITY OF CUPERTINO Q-UL(
WATER NEATER
CITY OF
• CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
,3vYL40V�, c) 0 G � � -��
Building Address:
0153 Z,*c� wood Df
Owner's Name: Phone #:
7ok.vt d53 - 35 1
Contractor: Phone #: 60- 15- 1 - -713 1
AFFordable WCktU PeaferS
Fax #: bbl - �Sy - 9SSc
Cupertino Business License #: Contractor State License #:
a6fS6 6�-7369
Contact: Phone #: (,G1 - S9_ o ,} o
Scot--r LitfileField
Fax #: (obl -�Sq- gsSb
• Building Permit Info:
Bld ❑ Elect ❑ Plumb Mech ❑
Residential Commercial ❑
Job Description:
" e- Q-A A Q
Strapped On Platform ❑ Bonded New Location ❑ Replacement
Valuation: I 1
Green Building Check must be completed and attached to this application.
• Green Building Points achieved:
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
IOUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
10153 21011wood 7r , d-6 60r?
OWNER'S NAME: Avg /1'1¢,1 an PHONE # `/0�-ot5-3 - y5 71
GENERAL CONTRACTOR: r rpb4� Wa L r 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