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07020047 CITY OF CUPERTINO BUILDING DIVISION PERMIT NFI�IV� TI�N• BUIL IN KESS: PERMIT NO. 1U /� HAZELBROOK DR AFFORDtiBLE WATER HEATERS & 07020047 OWNER'S NAME: PERMIT ISSUE DATE MRS. HAN 24707 SAN FERNANDO RD 02/08/2007 jNE: SANITARY NO. CONTROL NO. (661) 2!i9-7131 ABUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH i 00 LICENSED CONTRACTOR'S DECLARATION Job Description U t= 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Z with Section 70()0)a(Division 3 of the Business and Professions Code,and my license isUJ WATER BEATER REPLACEMENT =y in full force and effe L 10 a r ? License Class Lic•# t— Date_ Contractor ARCHITECTS DECLARATION i < I understand my plans shall be used as public records )yU U.t Licensed Professional y; OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractors License Law for the p 00 following reason.(Section 7031.5,Business and Professions Code:Any city or county < Q, which requires a permit to construct,alter,improve,demolish,or repair any structure y prior ui 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 Incense Law(Chapter 9 Sq.Ft.Floor Area e.t_ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $1200 u F F 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 Q p,N Number Occupancy Type not more than five hundred dollars(5500). 326280,17 :CT V ❑I,as owner of the property,or my employees with wages as thew sole compensation, will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law docs not apply to an owner of q p 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. cerise 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 OwnerDate WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury anc.of the following declarations: ❑I have and will maintain a Certificate of Consent to self-insure for worker's Compen- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ave and will maintain Worker's Compensation Insurance,as required by Section 700 of the Labor Code,for the performance of the work for which this permit is issued. My Warkees Co pensation Insurance carrier and Policy num ran Cartier. I k ' _n r� Policy No.: �1 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is forone 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 Workers'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 Oforthwith comply with such provisions or this permit shall be deemed revoked. z"'" CONSTRUCTION LENDING AGENCY (� 1 hereby affirm that there is a construction lending agency for the performance of _ a> the work for which this permit is issued(Sec.3097,Civ.C.) WA Lender's Name CI. 0, z Lender's Address V C 1 certify that I have read this application and state that the above information is IL ►'� correct.I agree to comply with all city and county ordinances and state laws relating to Ubuilding construction,and hereby authorim representatives of this City to enter upon the W above-mentioned property for inspection purposes. LL (We)agree to save,indemnify and keep harmless the City of Cupertino against p..4 to liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit Date g �+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SOURCE REGULATIONS. Re-roof; Signature of Applicant/Contractor Dare Type of Roof HAZARDOUS MATERIALS DISCLOSURE yp Will the applicant or future building occupant 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 roof 3 shall be inspected prior to any roofing material being installed. ❑Ycs [X'No If a root is installed without first obtaining an inspection,I agree to remove 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 all new Tlaterials for inspection. District? ❑Yes JNu I 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 does not currently have a tenant that it is my responsibility to notify the occupant of the requirements which 7ust be m poor to issuance of a Ct�ficT or Npancy. Signatul a of Applicant Date koAC All roof coverings to be Class "B"or better 'c Owner or autho d agent Date as Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 4'UPEkTINO Building Department JOB ADDRESS: PERMIT# ��Uj��;1v��'� .� iO -7S WkTeI h(-0ok 16r , OWNER'S NAME: PHONE # ©�- - GENERAL CONTRACTOR: AFS rAkh4 wU ser t-k re FAX # I am not using any subcontractors: (`Q.�T� Signature Date Please check applicable subcontractors and complete 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 3 ITEMS OF 6 PERMIT RECEIPT OPERATOR: amyw COPY # 1 Sec: Twp: Rng: Sub: Bl{: Lot: APN . . . . . . . . . 32528047 .00 DATE ISSUED. . . . . . . : 02/08/2007 RECEIPT #. . . . . . . . . : BSD00000422 REFERENCE ID # . . . : 07320047 SITE ADDRESS 21075 HAZELBROOK DR SUBDIVISION CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER MRS. HAN ADDRESS . . . . . . . . . . : 21075 HAZELBROOK DR CITY/STATE/ZIP CUPERTINO, CA 95014 RECEIVED FROM RECEIPT INTERFACE CONTRACTOR LEONCE ROUX LIC # 26850 COMPANY AFFORDABLE WATER HEATERS & ADDRESS 24707 SAN FERNANDO RD CITY/STATE/ZIP . . . : NEWHALL, 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. 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 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 168 . 04 2463 --------------- TOTAL RECEIPT 168. 04 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- -------------------- 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING CITY OF C UPERTINO WATER HEATER CUPEt�TINO PERMIT APPLICATION FORM APN# Date: Building Address: Owner's Name: Phone#: M S CA f\ `f - X55- 3 s Contractor: More: (,-(t l License#: G b e u0 aTe a'5"1 -2 13 ► (0- ) 3�e Contact: Phone: (Pb 1 Cupertino Business License#: coT Li iT l e,Fi'e 1 A 4 Building Permit Info: d Bld ❑ Elect Ed Plumb Mech Job Description: Residential Commercial ❑ 2 aCQ 'lS �Ioui gr Cost of Project: Strapped P, On Platform Bonded New Location ❑ Re lacement Qty. if Fee Group A licable Fee ID Fee Description BPWHEAe ID Water Heater/Vent BUILDING PPER ffFEE PlumbingPermit Issuance PLUMBING BENERGY Ener BUILDING BUSLIC Business License BUILDING