08100133 CITY OF CUPERTINO as
BUILDING DIVISION PERIVIIT =Ci)NTRACTQRINk'URIYIATIQN:>
.rte - a, „x:, ur `•t.>. ,;.w-,
BUILDING ADDRESS: PERMIT NO.
10480 AINSWORTH l)R NEW STRU('TUE PIJUMRTNn TN(' nR1 nn1 31
OWNER'S NAME. PERMIT ISSUBDATE
WEE corn T C 211!P n nnnv i 9 'I 7 n 3— 0
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�— �" CONTROL NO
(408) 364-2143
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
ELECT BLDG PLUMB MECH
0 0 0 0
m0Ci LICENSED CONTRACTOR'S DECLARATION
m 1 hereby affirm that I am licensed mules provide.a Chapter 9(cammcming Job Description
with Section 7")ofDivision 3 oflhe Bmn=and Nnfcuiom Code.and my limner u
itndBfin L force REPLC WTR HEATER
�
y z Lhecnac Class L,c.11
n F I Da^ Conlracur
e ARCHITECT'S DECLARATION
y I undauund my plans shall W used as public retards
Di
k C Licensed professional
OWNER-BUILDER DECLARATION
a�i x 1 hereby a?m that 1 am exempt from the Contranor,Lkcnse Law for Ute
Z pe O following reason.(Section 7M 1.5,Business and Professions Cade:Any city or county
_ which requires a Permit in ceramics.mar.improve.dmmltsh,or repair any,uusem.
poor in its issuance.also requires thcapplicant forsuch permit to file a signed statement
pp G dutheullecnselpuraunlmlWprovidonsofthcCOnuacmM1llcenselaw(ChaPm9 Sq.Ft.Floor Area Valuation
sr '(cmnmemingwith Section7000)o(DIvHion3ofthe Busies udPmfmions Codc)or
ERE,�
at M or exempt theWrom and thte basis for the Wegcd exempdav Any vialauon of $800
Section 7031.5 by any app iesnt fm d permit mbjcros the dppluant m a chwl ponalty of APN Number Occupancy Type
not more than five hundred dollars(SM.
�1.u�wner of the propxty,ormY emPloYeuwW cages uthte'v sole rnmpenssdon, 32646002 . 00
will do the wart,and the structure b notintended or offered fonale(Sec.7W,Budws
and Profealans Cads:The Carteret License Law does oat apply m an burro of Required Inspections
propany wh,builds or improves them on,and who does such wmk hmuelf or through his
awe amplayees,provided that such Improvemeeu me not Intended oroRemd for We If.
how.,the building or improw:saam is sold within rote year of completion.the ownor-
build will have the burden of proving that W did rot Wild a improve far purpose of
v
L u owner of the propeny,sm reclasmely considering with licensed ronmacmn m
cmumxt the projm(Sec.7014,Buvoecs and Prn(essums Cade:)The Conmaemrs U.
tense law dam not apply m an owner of property who Wilds ar hmprovu thereon.and
who conuacu ter such prolecu with amnmcmr(s)licensed punuam m the Convcmrs
Lkenx law
❑lamex pt Set ,Bk PC for NU rtsson
Owns —
Data
ER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of poijus,one of dm following declaradona:
1 have and will ma Bad.a Curifmuu of Consent to self-huure par WOrk<rsCompen-
hon,m provided for by Section 7700 of the labor Code.for the Performance of the
work for which this permit is issued
❑1 have and will maintain Workers Compensates I turanm,u mquimd by Section
3700 of the lather Cade,for dre performance of the work for which thus permit is issued
My Worker,Compensation Insurance tamer and Pohry number am:
Comm- _ Policy No
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(TTU=I.need rat W coreplamd if the pemh,is foram hundred dollar(SI W)
or lei)
1 comfy that in the performance of the work for which this permit u issued 1 mail nor
I employ any person in any maorcr as obuo sub)cetmt 'a ompemadon
Laws of c.lifomi.Date
Applicant -
NOTICE To APPLICANT:IL after makin Qda'ffMW1F bfVxCmphm.you should
become suhim in the Wo Lau,Compcasadon provhdem of the Taber Cede,you mum
.,O forthwith comply with such provisions m Nu Permit shall W deemed revoked.
'Z CONSTRUCTION LENDING AGENCY
Z IWrebyaRirm that ft.has coutrocd.lendhngageny,for duperfomance a( '
ai
the work fur which this permit at h cued(See.3097,Civ.C.)
z Lon�s AEAm^
U O 1 ratify that I hate mad Ws application and mute Nu the aWw hnfam itim Is
comeL 1 agree W empty with all city and county ordinances and subs laws mining to
U Wilding constructor,and hereby solitaire repmlcnudmcs of this city in on=upon the
4 above-mentioned propeny for inspection purposes
(We)agora m save,indemnify and keep hamksm the City of Cuperono against
rr/) liabilities.pagmenu,cmu and expenses which may in any way amuc against and City
fJ Z In consequence of the granting ParmiL
APPLICA D DS D WILL COMPLY WITH ALL N N-POINT Issued by Date
SOUR / _
g/ Re-roofs Q
Signewm 'Cut.RD r Da
HAZARDOUS MAiERIALSDISCLOSURE Type of Roof
Will dm applicant or forum building occupant smrc or handle has hex material
ss deMcd by the Cupertino Municipal Code.Chapter 9.13.and thm Health and Safety
Code,Section M532(a)? All roofs shall be inspected prior to any roofing material being installed.
0Yes
,11ft will the apluicam or to,.. dc
rt Wilding occupant use equipment or viw which If a roof is installed without first obtaining an inspection,I agree to remove
t hvardnus air conumiriants as defined by the Bay Arm Nr Quality Managemcm all new materials for inspection.
Wct7
❑Yes 4U(Nu
1 have mil the huudnus ro uoeH mquiremcnu under Chapter 6.95 or the Celoor.
nia HCalN Cods.Sccmmu25515.25533 nd255341urihnaand thnlfdlt thwlAng
Deus not eurrtnthY a t it u my responsibility m badly thm occupant of thte
mgotmvenu cam het arm issuance er,Ccrof?ate ar apm Signatureof Applicant Date
(/
70(J( All roof coverings to be Class'%¢,'or better
Ow Na a n1 Da¢
%_ ,
CITY 'OF CUPERTINO
• 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
. COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32646002 . 00
DATE ISSUED. . . . . . . : 10/21/2008
RECEIPT # . . . . . . . . . : BS000006424
REFERENCE ID # . . . : 08100133
SITE ADDRESS . . . . . : 10480 AINSWORTH DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : LEE SHEILA S AND LO DANIEL M
ADDRESS . . . . . . . . . . : 10480 AINSWORTH DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1045
RECEIVED FROM . . . . : SHEILA S LEE
CONTRACTOR . . . . . . . : LEON FRIDLIB LIC # 26052
COMPANY . . . . . . . . . . : NEW STRUCTURE PLUMBING INC
ADDRESS . . . . . . . . . . : P OBOX 111143
CITY/STATE/ZIP . . . : CAMPBELL, CA 95011
TELEPHONE . . . . . . . . : (408) 364-2143
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------ --------- ---------- ---------- ----------
1BSEISMICR VALUATION 800 . 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
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- -------- --------------------
CREDIT CARD 106 . 56 MC
---------------
TOTAL RECEIPT 106 . 56
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER
•
CITY OF CUPERTINO
WATER HEATER
•CUPEkTINO PERMIT APPLICATION FORM
APN #2A �o , / / 0 �' d j -- I Date: ,/
//
`� �P J 0
Building Address:
Owner's Name: Phone #:
79 9"- YX
Contractor: Phone #: < 9M _9 7a
�(GC�rt b(�l�J _• Fax #:
Cupertino Business License: Contractor State License #:
oZfov ��
Contact: Phone #:
Fax #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Residential Commercial ❑
Job Description:
Strapped ®' On Platform 4lEr Bonded ❑ New Location ❑ Replacement ❑
Valuation (cost of project): A3_e� v
Project Size: Express Fo�j Standard ❑ Large ❑ Major ❑ l
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to
the application or if applicable, include in plan set & the sheet index.
Green Building Points achieved:
Revised 6/16/08
CITY OF CUPERTINO s
WATER HEATER
CUPERTINO PERMIT APPLICATION FORM •
Quantity Fee ID Fee Description Fee Permit Type
Group
1PWHEATR Commercial Water B PCWHEATR
HeaterNent
1BSEISMICOM Seismic Commercial B
1 1PRWHEATR Residential Water B PRWHEATR
( HeaterNent
1BSEISMICRE Seismic Residential B
1PPERMITFEE Plumbing Permit P
I 1TRAVDOC Travel & B
Documentation
1BUSLIC Business License B