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07090084 CITE'OF CUPERTINO BUILDING DIVISION PERMIT tEUIIMATI€��Y* PERMIT NO. aulL�rj JyBEsMC CLELLAN RD PLUMB IN TIME INC 07090084 b PERMIT ISSUE DATE OWNER'S NAME: ADAM WU 360 MEMORIAL DR 09/14/2007 SANITARY NO. CONTROL NO. ,YE: (866) 293-3031 BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH p p LICENSED CONTRACTOR'S DECLARATION Job DCSCnptlOn uJ P I hereby affirm that I am licensed under provisions of Chapter 9(commencing :U U with Section 7000)of Division 3 of the Business and Professions Code,and my license is REPLACE WATER HEATER 40 GAL GAS. y in full Corce and Of Vq _ ? License Class Lic•# Date Contractor A CHrrEcTs DECLARATION i < I understand my plans shall be used as public records >yU P.y Licensed Professional : a OWNER-BUILDER DECLARATION ja I hereby affirm that I am exempt from the Contractor's License Law for the '00 following reason.(Section 7031.5,Business and Professions Code:Any city or county m which requires a permit to construct,alter,improve,demolish,or repair any structure Z y prior to its issuance,also requires the applicant for such permit to file a signed statement rea Valuation • a that he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9 Sq.Ft.Floor Ar e fs- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $700 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 Number Occupancy Type not more than five hundred dollars(3500). 3560402 D ❑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 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.). ❑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 Law does not apply to an owner of property who builds or improves thereon,and. who contracts for such projects with a contractors)licensed pursuant to the Contractor's 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: ❑[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. ❑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 Worker's corn as on Insurance carrier and Policy number to Policy No.:EI Car ier. U�S CERTIFICATE OF EXEMPTION FROM WORKERS' 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 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 Qforthwith comply with such provisions or this permit shall be deemed revoked. Z, CONSTRUCTION LENDING AGENCY [~a I hereby affirm that there is a construction lending agency for the performance of CY.� the work for which this permit is issued(Sec.3097.Civ.C.) WW A Lender's Name a z Lender's Address U I certify that 1 have read this application and state that the above information is G3. " correct.I agree to comply with all city and county ordinances and state laws relating to Ubuilding construction.and hereby authorize representatives of this city to enter upon the a above-mentioned property for in cuon purposes. (We)agree to save,i m .y and keep harmless thc City of Cupertino against y C� liabilities,judgments,cos nses which may in any way accrue against said City U Z in consequence of rhe C this permit. Date APPLICANT UND DS AND IL .CO L WITH ALL ON-POINT Issued by: SOURCE REGU a 9 Re-roofs S natu Appli ontractor Date Type Of)�.00f HAZARDOUS MA ALS DISCLOSURE 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 Safely Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. (:]yes /// If a roof 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 rr aterials for inspection. District? ❑Yes I have read the s materials requirements under Chapter 6.95 of the Califor- nia Health&Safety coons 25505.25533 and 25534.I u d that if the building docs not cuncntl tenant tha ' ism pons. 'ity tify the o t of the rcyuircmcnts w be met p r orrice ono ate of occu Signature of Applicant Date All roof coverings to be Class "B"or better mer authorized agent are CITY OF CUPERTINO 3 ITEMS OF 9 PERMIT' RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Bll:: Lot: APN . . . . . . . . . 35604025. 00 DATE ISSUED. . . . . . . : 09,'14/2007 RECEIPT #. . . . . . . . . : BS000002639 REFERENCE ID # . . . : 07090084 SITE ADDRESS . . . . . : 22: 96 MC CLELLAN RD SUBDIVISION . . . . . . : CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . . ADIM WU ADDRESS . . . . . . . . . . : 22398 MCCLELLAN RD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2753 RECEIVED FROM . . . . : PLUMB IN TIME CONTRACTOR . . . . . . . : PAUL HENDRIXSON LIC # 27607 COMPANY . . . . . . . . . . : PLUMB IN TIME INC ADDRESS . . . . . . . . . . : 360 MEMORIAL DR CITY/STATE/ZIP . . . : CIRYSTAL LAKE, IL 60014 TELEPHONE . . . . . . . . : (866)293-3031 FEE ID UNIT QUANTITY 2MOUNT 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 40.79 0. 00 40.79 0. 00 ----------- ---------- ---------- ---------- TOTAL PERMIT 86 .44 0. 00 86 .44 0. 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING CITY OF CUPERTINO *OF WATER HEATER CUPEkTINO PERMIT APPLICATION FORM APN# o// o 0 Date: �" Building Address: 'aa C C.1.cLLuv) <Z0 Owner's Name: �u �rV Phone k vin v� �35� Contractor: Phone: License#: L.0 b• •��T��ne %66.29 - 3C-31 x voy CiAS'193 Contact: Phone: Cupertino Business License#: a7bo7 Building Permit Info: Bldg ❑ Elect ( Plumb Mech Ifn Job Description: Residential Commercial ❑ Cost of Project: Strapped On Platform 19— Bonded C New Location ❑ Replacement Qty. if Applicable Fee ID Fee Description Fee Group BPWHEATER `Vater Heater/Vent BUILDING PPERMITFEE Plumbing Permit Issuance PLUMBING BENERGY Energy BUII.DING BUSLIC Business License BUILDING Community Development P10300 Torre Avenue Cupertino CA 95014 a Telephone(408) 777-3228 C"YOF Fax(408)777-3333 "'UPEkTINO Building Department JOB ADDRESS: PERMIT # OWNER'S NAME: PHONE # , J/ , GENERAL CONTRACTOR: FAX # I am not using any subcontractors: 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 --" er/Contractor Signa Date