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07090025 CITY OF CUPERTINO ) BUILDING DIVISION PERMIT BUILDING ADDRESS: PERMIT NO. 21557 RAINBOW DR CUPERTITO PLUMBING 07090025 OWNER'S NAME: PERMIT ISSUE DATE KIMSEY ROY B AND SHIRLEE 1300 DELL AVE 09/07/2007 NE: SANITARY NO. CONTROL NO. (408) 253-0618 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 00 LICENSED CONTRACTOR'S DECLARATION V i^- 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description :z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is REPLACE WATER HEATER. y in full force and effect. t ? License Class Lic.i Date Contractor ARCHITECTS DECLARATION i a< I understand my plans shall be used as public records >yU 'u.y Licensed Professional 'y OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the in o following reason.(Section 7031.5,Business and Professions Code:Any city or county Qi which requires a permit to construct,alter,improve,demolish,or repair any structure z y priorto 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 q.Ft.Floor Area Valuation F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $1200 9 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 ofNumber Occupancy Type not more than five hundred dollars($500} 3 5 6 2 3 0 2 E 'V( ❑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.7041,Business Required Inspections and Professions Code:The Contractor's License Law does 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 be 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 Contractors 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 Contractors License Law. ❑I am exem nder 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 I have and will maintain a Certificate of Consent to self-insure for WorkeesCompcn- 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 Workers Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Workers Compensation Insurance carrier and Policy number arc: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is Cor one hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued,l shall not employ any person in any mIc�so a�.to�comc subject to the Workcrs'Compensation Laws of Califomia.J;atc "I 7�U Applicant– re-'* 4 4-i-g NOTICE TO APPLICA :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 2CONSTRUCTION LENDING AGENCY E"rte. I hereby affirm that there is a construction lending agency for the performance of IYc> the work for which this permit is issued(Sec.3097,Civ.C.) W Q L.endcr's Name Z Lender's Address U C I certify that I have read this application and state that the above information is V," correct.I agree to comply with all city and county ordinances and state laws relating to OU building construction,and hereby authorize representatives of this city to enter upon the W above-mentioned properly for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against t) liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. -.y �1-z'a✓ 5��' Re-roofs Signature of Applicant/Contraclor Date HAZARDOUS MATERIALS DISCLOSURE Type of Rc of 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(x)? All roofs sliall be inspected prior to any roofing material being installed. ❑Yes QNVo 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 SNo 1 have read the hazardous materials requirements under Chapter6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if Ute building docs not currently have a tenant,that it is my responsibility to notify the occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. Signature c f Applicant Date l�'Py' 1'�"`' �i/�/C,) All roof coverings to be Class"B"or better Owner or authorized agent Date CITY OF �UPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 35623028. 00 DATE ISSUED. . . . . . . : 09/07/2007 RECEIPT #. . . . . . . . . . BS000002574 REFERENCE ID # . . . : 07090025 SITE ADDRESS . . . . . : 21557 RAINBOW DR SUBDIVISION . . . . . . . CITY CUFERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : KINSEY ROY B AND SHIRLEE ADDRESS . . . . . . . . . . : 21557 RAINBOW DR CITY/STATE/ZIP . . . : CUFERTINO CA, 95014-4816 RECEIVED FROM . . . . : ROY B KIMSEY CONTRACTOR . . . . . . . : CAFDIA, FRANK L LIC # 612 COMPANY CUFERTINO PLUMBING ADDRESS 13CO DELL AVE CITY/STATE/ZIP . . . : CAN:PBELL, CA 95008 TELEPHONE (4C8) 253-0618 FEE ID UNIT QUANTITY F.MOUNT 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 40 .790. 00 40.79 0. 00 -- -------- ---------- ---------- ---------- TOTAL PERMIT 86.44 0. 00 86 .44 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 86 .44 VISA --------------- TOTAL RECEIPT 86 .44 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ------------------ 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING . CITY OF CUPERTINO C10-Z�� 0 o C21-5- WATER WATER HEATER CUPEROF TINO PERMIT APPLICATION FORM APN# Dat9 7/O/ 0 2 ?, c_, v Building Address: �� %� �o,,l Vr, v.� Owner's Name: / k" /Phone#: �y ontFacto,:: Phoit- License,#: Capt ,- 7--/,-7k Contact: Phone: Cupertino Business License#: / Building Permit Info: Bld ❑ Elect ' Plumb Mech Job Description. Residential 4 Commercial ❑ Cost of Project: z o 0 Strapped On Platform Bonded New Location ❑ Replacement's Qty. if A lic f Fee ID Fee Description Fee Group. BPWHEATER _ `Vater Heater/Vent BUILDING PPERMITFEE Plumbing Permit Issuance PLUMBING BENERGY Energy BUILDING BUSLIC Business License BUILDING Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 CITY OF 7WERTINO BuildinDe a.rtment JOB ADDRESS: ,� - PERMIT # � / 5 f J 7 Hca, /,q,✓ 1-2 v e, '7 0 '? ZS, OWNER'S NAME: PHONE # �' Zf 7 t2 z GENERAL CONTRACTO C u reg>� I'w +��' FAX # I am not using any subcontractors: E ZZ Signature Date Please check applicable subcontractors and co m fete the followin 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 ZI-7 7 Owner/Contractor Signature Date