06060062 CITY OF CUPERTINO
BUILDING Dr.7-SION PERMIT C� I' RA TQR:I�t ItM�4TI�l�t: '
BUILDING ADDRESS: PLUMB IN TIME ,INC PERMIT No.06060062
10919 FESTIVAL
OWNER'S NAME: PERMITLSSUEDATE
STEVEN MACK 360 MEMORIAL DR STE J40 061081200r,
VE: SANITARY NO. CONTROL NO.
(866) 293-3031
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION
m 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
U with Section 7000)of Division 3 of the Business and Prof sst ns Code, y license is
h=y in full force and c eco REPLACE HOT WATER HEATER 50 GAL GAS
i ? License lass Lic.8
t❑ Date Contractor —
– ARCHITECTS DEC ION
mU 1 understand my plans shall be used as public records
•4
G H Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
i4 0.1 which requires a permit to construct,alter,improve.demolish,or repair any structure $500
Z w 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 Sq.Ft.Floor Area Valuation
t- (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(5500). ? Occupancy Type
❑1,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 docs rat apply to an owner of Required Inspections
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.). „}
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's u. ~~-�
cense Law does not apply to an owner of property who builds or improves thereon,
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
❑1 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:
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I 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 W r es Compensation Insu ce carrier and Policy numI511
m
Ca2211110No
If CERTIFICATEOFEXEMPTION FR ORKERS'
Gla PENSATTON 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,1 shall not
employ any person in any manner so as to became subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
z , CONSTRUCTION LENDING AGENCY
(�Cn I hereby affirm that there is a construction lending agency for the performance of
> Inc work for which this permit is issued(Sec.3097,Civ.C.)
Lenders Name
z Lcndees Address
Y)Q I certify that I have read this application and state that the above information is
LL.►r correct.I agree to comply with all city and county ordinances and state laws relating to
O U building construction,and hereby authorim representatives of this city to enter upon the
OW.h above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
o_4 to liabilities,judgments,costs and expenses which may in anyway accrue against said City
U Z in consequence of the granting of this permit.
APPLIC UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date (�-
SO EGULA NS. �^
Re-roofs
ignatu f Applicant/Con for Date
HAZARDOUS MATERIA Isc1 osuRE Type of Roof
V,the applicant or future building occ t store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12•and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant.that it is my responsibility to notify the occupant of the
rcqur s which m be o iso certinc�a _up�cy. Signature of Applicant Date
�� All roof coverings to be Class"B"or better
Owner authorized agent Date
Community Development
{y 10300 Torre Avenue
rte, Cupertino CA 95014
Telephone(408)777-3228
av OF Fax(408)777-3333
7UPEkTINO
Building Department
JOB
DDRESS,: /� 0 PERMIT # e"2
s ,J/Z
01W—
OWNER'S NAME: ,Qi�, PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: CP Qty
Signature Date
Please check applicable subcontractors ancom lete the following information:
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
:m 1 of 4 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 36217021 . 00
DATE ISSUED. . . . . . . : 06/08/2006
RECEIPT # . . . . . . . . . : 34747
REFERENCE ID # . . . : 06060062
SITE ADDRESS . . . . . : 10919 FESTIVAL DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . . STEVEN MACK
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
:: CITE' OF CUPERTINO
WATER HEATER
CUP kT"INO PERMIT APPLICATION FORM
APN
.� 71 Date:
Building Address: y
I0
Owne'r's Name: Phone#:
Contractor.
License #:
Contaort:
Cupertino Business License #:
Building Permit Info: -
i
Bldg i❑ Elect [GY
Plumb 'x Mech [1'
Job 136scription:
w (, St, j g,
Residdntial ( Commercial Q
Cost of Project:
C-)C)
Strapped _On Platform Bonded
New Location Replacement
ptyJ if
Appli' able Fee ID Fee DescriptionFee Group
BPWHEATER Water Heater/Vent
PPERMIT EEE BUILDING
Plumbing Permit Issuance PLUMBING
BEN ERGY _ Energy BUILDING
BUSLIC Business License BUILDING
i
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