06040027 (2) CITY OF CUPERTINO
BUILDING DIVISIONPERMIT CONTRACTOR�INFORMATPON
BUILDING ADDRESS: METRO MECHANICAL INC PERMIT No 06040027
4
OWNER'S NAME: PERMIT ISSUE DATE
CINDI MA 1000 N RAND RD. - #112 04/05/2006
ONE: SANITARY N0, CONTROL NO.
(866) 293-3031
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
LE 0 t�
Y I°u°F I hereby affirmtat I am CONTRACTORS under ppDECLARATIONshmster 9(commencing Job Description
�it`$ with Section 70011)of Division 3 of the Business and Profcsswm Code.and my licensee
n`°H
in fall tome aria eBect. it�E%G�cQ REPLACE HOT WATER HEATER/ 40 GAL GAS TALL 12YR
j�{? License Class C'Lk.M
Dow 4/CIN: > Contrulo"C —4J ;� T
_ACTS DECLARATION
3-6
I uskerstanJ my plans shall he used az puM1lic mcortls
FIN
,9k '�Z
wF Licensed Professtnnal 4
a0� OWNER-BUILDER DECLARATION S$y� ) � xaC^I
ai<E I toren afr.that I am exempt from the Convacur's License Law for the h.. .`
00 following rtamn.(Scetiun 71131.5.Business end Profasiom Code:Any city ar county
e 3 which requires a permit to mnslruet,alter,improve,demolish,m repair any structure $500
YZi prior w its issuance.also requires the applicant forsuch Permit file a signed shwment
< Nat hf N
e is licensed Finansom to Ne prommosoe Contractor's License Low(Chapwr 9 Sq.Ft. Floor Area dAtion
Y~S (commencing with Section 7000)of Division 3 ofthe Business and Professions Cook)or
that he u exempt therefrom books the bssfor the alleged exemption,My violation of
Secdon 7031.5 by any applicam fm a permit subjects Ne applicant to a civil penalty of ��v�jppps
not ream Nan five hundred dollars(55110). r Qe \
Vul
I,ss owner of the preperty,or my employees with wages as their now compensation,
will do the work and the swcture is not intended aoQeend Imsale(Sec.70th,Business
and Professions Cede:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds m i m proves thereon,and who does such work himal f ar duough his
assn cmploycas,provided that such improvements art not intended eroRered forsak.if,
however.Ne building or improvement is sold within one year of completion.the owner-
builder will have the burden of Proving Nat be did not build or improve four Purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.70",nosiness and Professions Cade:)The Contractor's Li-
cense law docs not apply on an owner of propeny.who builds or improve Merton,and
who contracts for such projecu with a controctor(s)licensed pursuant to the Contractors
License law.
❑I am exempt under S. .B R P C for this mason
Owner Dew
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury,can of 0w following declarations:
I ham and will maintain a Certificate of Consent o selr-Insure for WorkersCompen-
atien,m provided for by Section 3700 of Ne labor Cade,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Semon
37W of the Labor Code,for the performance of she work for which this permit is issued. '
My WorkeesnCompewtion Insurance carrier and Policy number are:
Cartier: 1}kl FI'L Policy No.:L-C. JL(Z IL(?O
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE .
(rhisscnioi sed not mcc mple ed ifft permit is Aurone hundred dollars($100)
less.)
1 cenifv Nm in the performance of Ne work for which this permit is issued,I shall not
employ any person in my mannerso ss to become subject to Ne Workeri Compensation
Laws of California.Dow
Applicant
NOTICE TO APPLICANT:If.aper making this Cenificate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Code,yen most
.,O foMwhh comply with such provisions or this Permit mail be deemed¢voted.
z.vy CONSTRUCTION LENDING AGENCY
(~ Ihembyaffirm that Nem is a construction lending agency ler tiro performance of
Ci the work for which Nu permit u issued(Sec.3037,Civ.C.)
aA Lenders Name
z Inncur's Address
U Q 1 certify Nat 1 have had this application and show that the show information is
LL,F Conon.l agree to comply with all city and county onlinames and sum laws muting to
pU building construction,and hereby amhorim mpmsenutives or this city to enter upon dm
H 1 aMvcmcmioscd property for impecdon purposes
(We)agree to ave,indemnify and keep harmless On City of Cupertino against
y liabilities.judgement.costs and expenses which may in any way acmue against said City
f
U Z, APPL CANT UNDERSTANDS AIND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
tco Re-roofs
StSignatureof AppbcaHAZARDOUS MATERIALS DISCLOSURE Dow ,I,
ype of Roof
Will the applicant or forum Wilding occupant store or handle heamamd
material
U defined by the Cupertino m) pe the H
Municipal Code,Chapter 9.12,and
IN anmtl Safety
Code,Section 255320)?
❑You MNn All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant am equipment ar devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hvaMnaz air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? ,,ee,,
❑Yu p No
I have read the hvaNtms materials requiremcnd under Chapter 6,95 of the Cxlifor.
nu HcalN&Safety Corfu Eccdons255115.25533mdn53.1unWmwdNwifft Wilding
does not currently have a wnmt Naz it 4 my wo,canibility to sanity the oeeuPmt of the
re mem.wmm�musteemetpnorwomarecefaccmBeatearacupmoy. Signature of Applicant Date
Owner or authorised agent Dam All roof coverings to be Class "B"or better
CITY OF CUPERTINO
eem 2 of 2 PERMIT RECEIPT OPERATOR: amyw
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 31601143 . 00
DATE ISSUED. . . . . . . : 04/05/2006
RECEIPT # . . . . . . . . . : 33856
REFERENCE ID # . . . : 06040027
SITE ADDRESS . . . . . : 20421 VIA PORTOFINO
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER CINDI MA
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : JASON SCHERR
CONTRACTOR . . . . . . . : PAUL HENDRIXSON LIC # 27607
COMPANY . . . . . . . . . . : METRO MECHANICAL INC
ADDRESS . . . . . . . . . . : 1000 N RAND RD, 4112
CITY/STATE/ZIP . . . : WAUCONDA, IL 60084
TELEPHONE . . . . . . . . : (866) 293-3031
*FEE 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
----------------- ------------ ------------------
CHECK 168 . 04 22017
TOTAL RECEIPT 168 . 04
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
a
•
PV
Community Development
10300 Torre rtinno
CCA 95014
Telephone(408)777-3228
CITY OF Fax(408) 777-3333
WUPEkTINO
Building Department
JOB ADDRESS: PERMIT # Z
�o,7 o6
OWNER'S NAME: PHONE O q I
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
21 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 W040021
• WATER HEATER
CUPI TING PERMIT APPLICATION FORM
APN # Date:
Buildi g Address:
a- L 11L0
Owne 's Nam6: Phone#:
m� Mcg yc8—��i� - 9108
Contr ctor: License #:
Conta't:
VcIA Cupertino Business License #:
Buildi ig Permit Info:
Bld I❑ Elect ❑ Plumb Mech ❑
Job D scription:
Rcsid ntial Commercial ❑
Cost o Project:
q ,-) LV L V
Strapp d On Platform LJ Bonded
• New I cation ❑ Re lacement ❑
Qty. if
A li able Fee ID Fee Descri tion
BPWHEATER Fee Grou
Water Heater/ Vent BUILDING
PPERMITFEE Plumbing Permit Issuance
PLUMBING
BEN ERGY
Ener y BUILDING
BUSLIC Business License BUILDING
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Cfgt)Aat Loge c oo ty
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