08040066 (2) CITY OF CUPERTWO
BUILDING DIVISION PERMIT COI�ITRAGORIIVURMAI eION1
$, PERMR NO.
BUILpir�GgpoDaTIPTOE LN FAST WATER HEATER 08040066
OW NEWS NAME: PERMIT ISSUE DATE
SUSAN BELTON 12601 132 AVE NE 04/09/2008
ONE SANITARY NO. CONTROL NO.
AacxlTTacrreNCINEER: EL �RPO
RMV/RPLC GAS WATR HEATER e� EC LOO
3 o p LICENSED CONTRACTOR'S DECLARATION
1 hereby.Kiel Wt 1 am licesed nunder prevision of Chapter 9(commencing Job Description
NN Section 7=)ofDivWaO 3 oft the Busin=reit Profaui es Code,and my lkens is
n N in full face and effees.
g? Uaenae Class, Lk.w
Dae Con DELL
ARCHITECTScot DECLARATION
I undersand my plans shall On used u public recoNa
yo Licensed Pnfesaional
a OWNER-BUILDER DECLARATION
i E I hemby allow that I am exempt from the Cwlract is License law far the
p O fallowing mason.(sacdan 71D 1.5,Business and Profession Cade:My city Or county
$ which requires a permit to ennWuc4 abet.bnpreve,demolim,a repair any romaure
zL" prior s its issuance.also nequims lhcapplicaut(or such permit On rite a signed awamem
�Is that he Is licensed pursuant o the prevision ofth Contractafa License Law(Chap=9 Sq.Ft. Floor Area Valuation
(commencing with Section 7000)of Dwis an 3 of the Bail.sod Prfordmu Code)lir
that he k emI
emerge therefrom therefrom and the India for the alleged exemption.Any violnlon of
Section 7011.5 by am applicant for.permit subjects the.Pplk.L m a 0111 penalty of APN Number Occupancy Type
ret mom dun 0w hundred dOWa L2300).
I,ssov=of de pmpmty,ormy=play=with wguuile'v sok compewilan,
will do the work,and theaouaure is rolkknded"offered foreak(Sa.7044.Busircas Required Inspections
and de:Profession CaTIe CmrcLicense ttor's LiLaw d=rem et apply an manor of q P
property who builds ser im prams demon,and who does such work himself ser through his
Own employ=,preAded than such imprmemenu are not Intended araReend formle.If,
however,Ne building or impmwnunt Is mid within an Inv of completion,Ne come.
builder will have W burden of Moving that h did am build or improv for purpose of
ask.).
0 1,u awe of the property.mat eachormly comme int with licimed conuaclas m
conmKs the pmj=(See 7044.Business and Prefrssion Coda)The Cmbsmr's U.
cone Law data Me apply in..owner of preperty who builds or impovn theme.and,
who conlnm for surd projects with sconaatnr(s)licensed pursuant in the commerce.
License Law.
❑I am.erre,,under See .Bk P C far this moan
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby a0bm under family of perjury mm of the following dee uWan:
haw and will maintain.Certificate,of Consent m self-loaam for Worker's Camper -
.u provided for by Saurian 3700 of the tabor Cade.for the Md...Of the
,-,for which Thi.Permit k inured.
❑1 haw end will maintsin Worker'.CompenWan In...u required by&.do.
3700 of the labor Cotler,for On performuceanfthe it far which this Mrsokis issued. '
My Wallace.Compensation Ineassnce canis and Policy number am:
Cartier. Polley No.:
CWTHICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thosedn read nth completed if the permit is foron hundred dollars(5100)
or lest)
I certify that he lie performance of the wart for which this peed,is loud,l fids not
employ any person In my mmnrs u in become abject in the Workers'Companudom -
Law of Ceifomia.Dam
Applicant
NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should
hcnmer subject in the Worker's Compensation provision of the Labor Code,you mud
.J Q k pe
forthwith comply with each pravWon a thrmit Nalme
l be deeed =ked.
„Z.ty CONSTRUCTION LENDING AGENCY
'f..m Ibemby affoo thu Nem isatmnmcdon lending agency for the poefermanco of
!Yi W work for which this permit Is issued(Sea 3197,Civ.C.) '
WgL, Lmdcr's Name
a Z Landeh Address
U O 1 certify that 1 haw cob this application acid dam that the above Information k
Iy ^. concur.l agmen in comply with all city and county mdinancee and seam law retailing a
.O rU^ building construction,and hereby auNodre representatives of this city to enter upon lit
aha-mentioned property for Lupeaian purposes.
y (We)agree to taw,indemnify and tact,humins,037 City of Contend.sgalnt
sow h Ikhilitiu.Judgmenq costs and expenses which may In my soy acme sgalmlaaid City
U in^ LIC NTcUNDERSTANDS Aof me johollot Of ND s NMIL
APPLICANT ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signuum of ApplinnuContmor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or furore building occupant nam or handle haurdous material
u&feed by the Cupertino Municipal Cade,Chapter 9.17.and the Health and Safety
Code,Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yn ❑No
Will the applicmt or future building occupier use equipment ar devl=which If a roof is installed without first obtaining an inspection,.1 agree to remove
t hvssdu
oalt
contaminants se derind by the Bsy Ara Air Quality MauCtmms all new materials for inspection.
Fir v a7
❑Yea ONO
1 haw mad Nc hvudun MM6213 mquirem ursundarChpmyh.95ofthe Califor.
nit HealthkSalceyCndc.ScWom MS05,25533 ud25534.1undentsndthuifde building
d=not currently hew s tenors Lou it it my ml MMIN11ty to notify the occupanL of the
mquimmmis which much met prior to issumce ofd certificate of Occupancy. Signature Of Applicant Date
Owner orautharxedagent DateAll roof coverings to be Class'?"or better
CITY OF CUPERTINO
• 4 ITEMS OF 24 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35930011. 00
DATE ISSUED. . . . . . . : 04/09/2008
RECEIPT # . . . . . . . . . : BS000004429
REFERENCE ID # . . . : 08040066
SITE ADDRESS . . . . . : 7565 TIPTOE IN
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER SUSAN BELTON
ADDRESS . . . . . . . . . . : 7565 TIPTOE LN
CITY/STATE/ZIP . : CUPERTINO CA, 95014-5835
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
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 1061'. 56 0. 00 106 . 56 0. 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER
Permit Not 0807 o()(10 V98194
(office use only)
City Of Cupertino Building Permit Application
• E-Mail: Building-Permits(cDcuaertino.org (Address is case sensitive).
Jobsite Address:7565 TIPTOE LN Date: 3/31/08
Assessor's Parcel Number:
Owners Name: BELTON, SUSAN Phone No: (408)252-1089
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 & tip code: KIRKLAND,WA 98034
State Contractor's LIC. No: 877489 Expiration Date: 5/31/08
Worker's 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.
y Community Development
10300 Tatra Avenue
Cupertino CA 95014
Telephone(408)777-3228
C, OF Fax(408)777-3333
0 CUPEkTINO
Building De � artment
JOB ADDRESS: 7565 TIPTOE LN PER V=# (08 O Q D /
OWNER'S NAME: BELTON, SUSAN PHONE# (408)252-1089 t0
GENERAL CONTRACTOR:FAST WATER HEATHER COMPAN FAX# 425-814-9516
I am not using any subcontractors:_ �"" f/ 3/31108
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets&Mllworle
Cement Finishing
Electrical
Excavation
Fencing
Flooring.Carpeting
Linoleum/Wood
Glass/ Glazing
• Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofmg
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date