07020046CITY OF C;UFhKiury
BL71LDING inVISiON PERMIT
BUILDING ADDRESS:
20627 SUNRISE DR
OWNER'S NAME:
LAWSON
JNE:
ARCHITECT/ENGINEER:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70(10) of Division 3 of the Business and Professions Code, and my license is
in full force and effecL d
LicenseLic. S
Class f
Date Contractor
ARCHITECTS DECLARATIO
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars MINI).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
AFFORDABLE WATER HEATERS &
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workces Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Warkerompensation Insurance carrier and Polity number are:
Carrier. 17<^�" �_ Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so as t4 become subject to the Workers' Compensation
Laws of California. Aatc
Applicant Y
NOTICE TO ADPt.I ANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
z CA CONSTRUCTION LENDING AGENCY
[� .�. I hereby affirm that there is a construction lending agency for the performance of
p(� the work for which this permit is issued (Sec. 3097, Civ. C.)
W Q Lender's Name
aLender's Address
Ure
I certify that I have ad this application and state that the above information is
UL � correct. I agree to comply with all city and county ordinances and state laws relating to
0U
building construction. and hereby authorize representatives of chis city to enter upon the
above-mentioned property for inspection purposes.
>4 nWi (We) agree to save, indemnify and keep harmless the City of Cupertino against
Hto liabilities, judgments, costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
►a APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
24707 SAN
(661)25')-7131
PERMIT NO.
07020046
PERMIT L95UE DATE
SANITARY NO.
Job Description
WATER HEATER REPLACEMENT
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as deftncd by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)7
❑ Yes PM
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District? ' `
❑ Yes u
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Cade, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements whichlust be met p? or to issuance of a Certificate of Occupancy.
c4-�•2 -k-o -7
Owner or auttlatzcd agent Date
Sq. Ft. Floor Area
35910021'
Issued b'
Re -roof:
Type of Zoof
$1400
Required Inspections
CONTROL NO.
BUILDING PERMIT INFO
ELECT PLUMB
Valuation
Occupancy 'lype
All roof:; shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new i naterials for inspection.
Signatuie of Applicant
All roof coverings to be Class "B" or better
Date
t:
CITY OF
r,UPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
PERMIT #
L1iGC
!
OWNER'S NAME: rn r . Lc�u., so
PHONE # q OX- J, - 3 b - e
GENERAL CONTRACTOR: p- Fo rdaA,l c, -r -
FAX #
I am not using any subcontractors: ri A - � - O 7
Si,;nature Date
anei rnmplPtP the following information:
ricazPc
%-i«%-r
a u% -&LL-
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
3 ITEMS OF 6
CITY OF CUPERTINO
PERMI`.' RECEIPT
Sec: TwP: Rng: Sub: B1]c: Lot:
APN 35910021.00
DATE ISSUED.......: 02/08/2007
RECEIPT #.......... BS)00000422
REFERENCE ID # ...: 07)20046
SITE ADDRESS 20527 SUNRISE DR
SUBDIVISION ......
CITY CU PERTINO
IMPACT AREA ......
OWNER LAISON
ADDRESS ..........
CITY/STATE/ZIP ...:
OPERATOR: amyw
COPY # : 1
RECEIVED FROM RECEIPT INTERFACE
CONTRACTOR LEONCE ROUX LIC # 26850
COMPANY AFFORDABLE WATER HEATERS &
ADDRESS 24707 SAN FERNANDO RD
CITY/STATE/ZIP NERHALL, CA 91321
TELEPHONE ........: (661)259-7131
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.D0
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
-------- ----------------------------
502 FINAL PLUMBING ENERGY
507 FINAL PLUMBING
VOICE ID DESCRIPTION
-------- ----------------------------
506 GAS TEST
CITY OF
CUPEt�TINO
CITY OF CUPERTINO
WATEEZ HEATER
PERMIT APPLICATION FORM
APN #
Building Address: CA
Owner's Name:
mc. Lc.�Soh
Contractor: rnon v w
AFFnfdGbio- ud&.Tet a re r Phonc: c� S0 1 l -� 13
Contact: — -
_
Building Permit Info:
Bld ❑ Elect
Job Description:
Residential Commercial ❑
U1ctle-r lot
Cost of Project:
Strapped On Platform ❑ Bonded
New Location ❑ Replacement [911 -
Qty. if
i lullXL'L a
Energy
l
Fee Descripti
ot)m'�--(p