06120056 (2) CITY OF CUPERTINO �T�+ ��r"�� -' 'x°y'�" '��',{,� �?;
'BUILDING DIVISION PERMIT � r"&T )RII�tkaOI;M�TIf)N W
eesti -�,,.. .v .e .V'
BURRING ADDRESS: PLUMB IN TIME ,INC FERMIT NO.06120056
11163 WILKIN
OWNER'S NAME: PERMIT ISSUE DATE
MIKE SHANNON 360 MEMORIAL DR STE 140 12 /1 -1 /2006
NE: SANITARY NO. CONTROL NO.
(866) 293-3031
ARCHITECUENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
imp LICENSED CONTRACTOR'S DECLARATION Job Description
w❑ I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
:iW with Section]Otg1)of Divisum3crbw Busin d of tom Cod • yAicenseu
inrallrnone" crtc" 1 REPLACE HOT WATER HEATER
t ya z Liacm ass Lie.x
w Dow Comracmr —
•pp CHrfECTS DEC RATION
i N I understand my plans shall W used a public records
u.ryV
Licensed Pmfcssional
p S
OWNER-BUILDERexempt
ColuaON
f n o I Wrehy alum that I I.J.caempt from the Cssors Co e:Any
Law(w the
:no O following mason.(Section 7M I. Business and Professors Code:Any city or county
$(ai which myuises a permit m constraq alter.improve,h Permivh,or repair any structom $500
_zy priormits isswntt.alw requites the applicant for such permit to tilt asigneJ sutemont
< that W is licensed pursuant to the provisions,of the Conuocwra License Law(Chapter 9 Sq. Ft. Floor Area Valuation
2 (commencing with Section 71(10)of Division 3 of the Business and Professions Code)or
a 5— mat he u exempt dmrcfaom and alta bais for the alleged exemption.My violation of
Section]031.5 by arty applicant fw a panni,wbjttu the applicant so a civil penalty o! r U U Occupancy Type
not mom than five hundred dollus(SSW).
1,as owner of the property,or my employees with wages u their salt compenauon,
will do the work,and the suunme is not inaMed or oRemd for ad.(Ss,.]pace,Busies
aM Prefesalons Codc:This Contractors Lime Law does tet apply In an owner or - Required Inspections
property who builds or improves flercon,and who does such work himself or through his
own employees,provided mat such imp even emu•m notimended oroff red for We.B.
however,the Wilding or unprownsent is cold within wee year of completion,the owner-
builder will have the burden of proving that he did not Wild or improve for purpose of
We.).
El 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.]Oad.Business and Profem aos Code:)The Coovaemh U.
ecru Law dean not apply w an owner of property who Wilds or improves thereon.and
who contracts for such projects with a eommmor(s)licensed pursuant in the Contractors
License law.
❑I am cacmpt undo See. .B&P C for this maw.
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby sfEsw under pwWty of perjury me of the following declarations:
1 ham and will maimuin a Certificate of Consent to self-insure for Worker.Compote
.tion.as Provided for by Section 39W of the labor Code.for the performance of the
work f which this permit is issued.
1 have and will maintain Workcrs Compensation Insurance,as required by Section
37W of we Labor Codc,for the pertormanca,of the work for which this permit is issued.
My Wor rs CampensauolC nWand
an
anni
ca
�EMPTONipyiey nyA�ram�
Gmi Q f�/liA /�//Pal` /FryA1-57
f ATEOF EMPfION 0 C
COMPENSATION INSURANCE
(This mention need nwbceompkmJ if the permit is fwone hundred dollars($100)
or less.)
1 cerofv that in the performance of the work fm which this Permit u issued.l shall not
employ any pawn in coy mm mrw as to become subject to Bre Workers Compensation
Laws or Ca iforoia Dam
Applicant
NOTICE TO APPLICANT:If.after making Nis Certificate of Escoutim,you should
became subject an the Worker's Competwdon powisiwu of the Lahw Cade.you muu
.J O forthwith comply with men provisions or this permit shall W domed ormand.
z N CONSfRUCfION LENDING AGENCY
[-+ 1 bemby a1Drm that thcpi u a conswednn lending agency for the performance of
C > the work for which this permit u Wand(Sce,3099,Civ.C.)
1 A Landers Name
7 z Undoes Address
U O I certify that 1 have read this application W sum that the above informadun is
coma.I agree to comply with all city and county ordinances and sone laws piloting to
0U building c0neuunian,and hereby authorim representatives of this city o cowl upon the
4
move-mnnuuncdpmpcny for nspecisonences put,ewhich ms.
(We)agree ro save,indemnify and keep harmless the City of Cupertino against
UN incoewitiiomenuegratsavdcxpiscrihichtheyin•raywayaammagainstaidCity 11 tj
U,Z^ A caLnrgnence oftheapung of a WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO E TON
-� Re-roofs
d'signiatche of pPlicanUConuxmr Dam
HAZARDOUS MATERIALSDISCLOSURE Type of Roof
W' Jmapplicamor future Wilding wcupantsmre or hatWle harardous material
as dcOned by the Cuprztlno Muni I Codc.chapter 9.12,and de Healon and Safety
Code.semen zss3z(,)]
❑Yes No All roofs shall-be inspected prior to any roofing material being installed.
Will me applicant or future Wilding occupant usecquipmem or devices whim If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air corner nu ss dermad by the Bay Arta Air Quality Mwgcmcnt all new materials for inspection.
Dn"os,] � P
❑Yes
Thaw:madmeluardmumaterfalsmquimmenmunde Chapwr6.95ofthe Cxiifor.
nice Health&Safety CWC,sceuam255(15.25533md255 , understaudmmifthe Wilding
dos no urrcndy hart a tenant,mu it u roy memo dity m rtoofy dm ottoman,of de
rats which muu m dorm iss f a Cereficam of 0av Signature of Applicant Date
'LX-1 -v
Ownc aammiredattnt Oam All roof coverings to be Class "B"or better
.k.. Community Development
%�� ✓ 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY Of Fax(408)777-3333
•CUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
II (}SOMI AV& OLOI 0
OWNER'S NAME: M1 -44¢ Bu
GENERAL CONTRACTOR FAX #
am not using any subcontractor --/ 3
Signature Date
Please check applicable subcontractors and com Tete the following information
SUBCONTRACTOR BUSINESS NAME BUSINE S 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
am 2 of 3 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35617044 . 00
DATE ISSUED. . . . . . . : 12/13/2006
RECEIPT # • • • • . . . . . : 37033
REFERENCE ID # . . . : 06120056
SITE ADDRESS . . . . . : 11163 WILKINSON AV
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER MIKE SHANNON
ADDRESS . . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : PLUMB IN TIME
CONTRACTOR . . . . . . . : PAUL HENDRIXSON LIC # 27607
COMPANY . . . . . . . . . . : PLUMB IN TIME INC
ADDRESS . . . . . . . . . . : 360 MEMORIAL DR STE 140
CITY/STATE/ZIP . . . : CRYSTAL LAKE, IL 60014
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
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
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CITY ()F CUpE Y 4 O(012005
c F TING WAT.Ep, � RT11
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• ! PE"ICATION FORM
APN 7
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Building Address: Date:
X1163 (�,IIC�hso --- t�lslod
owner' a
s N n I�Ue I
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Name: 1
Contractor: I ��n y\o Vi Phone M: j
I LAOS "aS) _ Liq gO
Contact: License#:
Buildin Cupertino Business
I g Permit Info License n:
Bldg I�
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Elect
I Job Description: �- Plumb ;
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f' Mech Q
f Residential
1 I Commercial
' Cost o Pr0-ect:
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Strapped
�n Platform LJ
Bonded
New Location Replacement
•
QtY.I if-
le
1 Fee ID
"WHEATER Fee Description
PPERMITfiEE Water Heater/Vent Fee Grou
BENEP,GY Piu bina Permit Issuance B�DFNG
BUSI.dC En rvy PLUMING
Business License BUILDING,
BUILDING
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