07090085foo
,mP
tV
U
:Z
t<c
t=z
�
iH
sw
>aU
W H
.oa
,ap0
<m�
� � H
'?a
=FG
SRF
CITY 0,F CUPERIENO
BUILDING DIVISION PERMIT
BUILD Ny ADDRESS:
450 MC CLELLAN RD
OWNER'S NAME:
CADA CARL C AND DORIS M
TTOrn I'
ARCHrMCTIENGINEER:
PLUMB ID TIME INC
360 MEMORIAL DR
(866)29_-3031
PERMIT NO.
07090085
PERMrr ISSUE DATE
09/14/2007
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
_ Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 700(l) of Division 3 of the Business and Professions Code, and my license is RE PL C E WATER ER HEATERr 40 GAL GAS.
in full force and eftec
License CI �• # �
Date Contractor UYIr LrY
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
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
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(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).
❑ 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. 7044, Business
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.).
❑ 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-
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 Contractor's
License Law_
❑ I am exempt under See. B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
J I have and will maintain a Certificate of Consent to self -insure for Worker'sCompen-
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 Worke/l's ComperycaLionn insurance carrier and Policy number am:
Cartier. V, i eet Jr 4 $ - Policy No.: Z/�7I 0�
YV_ 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
O forthwith comply with such provisions or this permit shall be deemed revoked.
Z , CONSTRUCTION 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
I certify that I have ad this application and state that the above information is
U
0 recorrect. I agree to comply with all city and county ordinances and state laws relating to
0 U building construction. and hereby authorize representatives of this city to enter upon the
W above-mentioned pro tty for inspection purposes.
fZ. (We) agree to. "ve, indemnify and keep harmless the City of Cupertino against
E, liabilities, judg n , costs and expenses which may in any way accrue against said City
U Z in consequen of � c granting this permit.
�—+ APPLICA U DERSTA A D WILL CO LY WITH AL NON DINT
SOURCE TION
S' n of Applican Cmnuactor Darc
HAZARDOUS MA A SCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Munfci I Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)7
0-yesNo
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminan;No
as fined by the Bay Arca Air Quality Management
District?
❑ Yes
I have read the piss materials requirements under Ch to 6.95 of the Caliror-
nia Health & Safetys o Sections 25505.25533 and 25534.1 u d UuuiCtbe building
docs mol currcnlliy/} %r f tenan4 drat 5t�s my cesponsibilily tiCy the ocstrpant pF the
rcyuircments whi st be met p � r of a Ce ate of Occuf"'(��L/
Sq. Ft. Floor Area
3560402:_g64Number
$700
Required Inspections
on
Type
Issued by : " Date �— l 4 -
Re -roofs
Type of Roof
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection,.I agree to remove
all new rr aterials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better
3 ITEMS OF 9
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Bl}:: Lot:
APN 35604021.00
DATE ISSUED.......: 09,'14/2007
RECEIPT #.........: BS000002639
REFERENCE ID # ...: 07090085
SITE ADDRESS .....: 221:50 MC CLELLAN RD
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......
OPERATOR: patg
COPY # : 1
OWNER CAI)A CARL C AND DORIS M TRUSTE
ADDRESS 22650 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 (8(i6)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
40.79
0.00
40.79
----------
0.00
----------
TOTAL PERMIT
-----------
86.44
----------
0.00
86.44
0.00
METHOD OF PAYMENT
-----------------
CASH
CHECK
TOTAL RECEIPT :
AMOUNT
---------------
7.26
252.06
---------------
259.32
VOICE ID DESCRIPTION
-------- ----------------------------
502 FINAL PLUMBING ENERGY
507 FINAL PLUMBING
REFERENCE NUMBER
--------------------
VOICE ID DESCRIPTION
-------- ----------------------------
506 GAS TEST
CrN OF
CUPEI�TINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
2 L� �a 4 L��L��, �2
PERMIT #
0 ?694r s
OWNER'S NAME:A�,.
PHONE # l ^ ;_ S
R:
GENERAL CONTRACTO,_� - i N 1 YYq-
FAX #
I am not using any subcontractors:
Signature
Please check applicable subcontractors and complete the following information:
Date
()weer/Contractor Si ate e Date
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
Tine
()weer/Contractor Si ate e Date
*OF
CUPEkTINO
CITY OF CIUPERTINO
WATER.'HEATER
PERMIT APPLICATION FORM
070V or -45
APN #
Water Heater / Vent
Date:
Building Address:
Plumbing Permit Issuance
PLUMBING
a t-1 So
cc Lc LLc�in �7
BUILDING
Owner's Name:
Business License
Phone #:
Cu.cL
%a��
Lj(>�& - )S-)- �►��
Contractor: I
Phone:
License #:
L.0 b• •h^7\ MC-
g66•ay • .3t� 31 ,T vtA
cigS'191
Contact:
Phone:
Cupertino Business License #:
1E
a-7bo7
Building Permit Info:
Bldg ❑ Elect ❑ Plumb CST
Mech ❑
Job Description:
�et.Ao:�C
Ll
Residential g
Commercial ❑
Cost of Project:
7c
Strapped On Platform Er Bonded
❑
9
New Location Replacement
Qty. if
Annlicahle Fee TD
Fee Descrintion
Fee Grout)
BPWHEATER
Water Heater / Vent
BUILDING
I PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING