07010172 CITY OF CUPERTINO y� i
BUILDING DIVISION PERMIT o . >. Qn'
PERMIT NO.
BUILDING ADDRESS:
tti TE
OWNER'S NAME:
ROLAND KENNER 360 MEMORIAL DR STE 140 01/29/2007
SANITARY NO. CONTROL NO.
ONE:
(866) 29'>-3031
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
J00 LICENSED CONTRACTOR'S DECLARATION Job Description
a V r- 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
C z L with Section 7000)of Division 3 of the Business and_Professions Code,a�d�y license is WATER HEATER 40 GAS GAS
v<a in ful��CHrMCTS
js
j z2 z LicenLic.#
p acContractor DEC R 10
9a'-t, I understand my plans shall be used as public records
yU
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U.y Licensed Professional
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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
K 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 Valuation
?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
$500
xF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y 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 of3592102 ? .tlt1N Number Occupancy Type
not more than rive hundred dollars(5500).
0 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 oroffered forsale(Sec.70",Business Required Inspections
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.).
0 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 Li-
cense Caw 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.
0 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:
�]i have and will maintain a Certificate of Consent to self-insure for Worker's Compcn-
sation,as provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
0 1 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.
or t �CQo�mpensation Insur'nce carrier turd Policy number are-
`„ liry No.:G �
CERTIFICA F 620
XEMPT7( FRO
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 to become subject to the Workcrs'Compensation
laws of California.Date
Applicant
NOTICE TO APPLICANT: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 OCONSTRUCTION LENDING AGENCY
�. I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
Lender's Address
U C) I certify that 1 have read this application and state that the above information is
LL, correct.I agree to comply with all city and county ordinances and state laws relating to
rJ U building construction,and hereby authorize representatives of this city to enter upon the
f-tl above-mentioned property for inspection Purposes.
GL (We)agree to save,indemnify and keep harmless the City of Cupertino against
two liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit.
►- APPLI NT U ERSTANDS AND WILL COMPLY WITH ALL NON-POI Issued by: Date _ Z
SOUR R IONS
�/ Re-roof:.
Sig urc o licanLlContractor °este
/
Type of Roof
HAZARDOUS MATERIAL SCLOSURE YP
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Muni ipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roof;shall be inspected prior to any roofing material being installed.
0 Yes No
id
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or futurering occupant use equipment or devices which
emit hazardous air contamina as defined by the Bay Area Air Quality Management all new -materials for inspection.
District?
0 Yes 0 No
1 have read the hazardous materials requirements under Chapicr 6.95 of the Califor-
nia Health&Safety Codc,Sections 25505,25533 and 25534.1 understand that if the building
docs of currently have a enant,Lha 't is my responsibility to notify the occupant of the
icy c is which must be met r to issuance of a Certificate of Occupancy. Signatul e of Applicant Date
All roof coverings to be Class"B" or better
Ocr authonrcd agent Datc
w
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY Of Fax(408)777-3333
'UPEkTINO
Buildirn De artment
JOB ADDRESS: -7 �N eti` '/ PERMIT #
�i�•tv SO/5� 6
�?0/ 7 Z
OWNER'S NAME: PHONE # 7 =- 6
GENERAL CONTRACTOR: - - FAX #
/- Zo
I am not using any subcontractors4
i
Signature Date
Please check applicable subcontractors and complete the followinginformation
SUBCONTRACTOR BUSIr[ESS 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
3 ITEMS OF 6 PERMIT' RECEIPT OPERATOR: suew
COPY # 1
Sec: Twp: Rng: Sub: B1}:: Lot :
APN . . . . . . . . : 35121022 . 00
DATE ISSUED. . . . . . . : 01/29/2007
RECEIPT #. . . . . . . . . : BSo00000338
REFERENCE ID # . . . : 07010172
SITE ADDRESS . . . . . : 7596 ERIN WY
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : RO:IAND KENNER
ADDRESS . . . . . . . . . . .
CITY/STATE/ZIP . . . : CU?ERTINO CA, 95014
RECEIVED FROM RECEIPT INTERFACE
CONTRACTOR PAJL HENDRIXSON LIC # 27607
COMPANY PLJMB 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
AT
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WATER HFA TES 1-;"41017
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