08100101 CITY OF CUPERTINOrx�v-w1 -( 'anr'
BUILDING DIVISION PERMIT "S"
.
BU
I G FSS: PERMIT NO.
NORTHGLEN SQ AFFORDABLE WATER HEATERS & 08100101
NER'S NAME: PERMIT ISSUE DATE
JASON CHANG 24707 RAILROAD AVE 10/17/2008
PHONE: SANITARY NO. CONTROL NO.
(661) 259-7131
ARCHITECT(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
w o o LICENSED CONTRACTOR'S DECLARATION O O O
1 Mmby affirm wt I+m licensed under provisions of Chapter 9(commencing Job Description
ON with SCnkn7n)(0)aTDIvlslahJOf the Business aaW Professions Cade. ntl haylicenseu REPLACE 40 GALLON WATER HEATER
a n Inrut)fameand➢t .�36 Lk.» f,2?36
D q i License class
D.m Contrxmr
C1-t1ELTS DEC ON
_ U I unscrewed my plans shall M used as public acorde
eco G Licensed professional
OWNER-BUILDER DECLARATION
1 hereby from this Tem esempt from the Contractors Liecnse Law for the
p o following ma30n.(Seedon 7(y]1.5,Business and Prefeafi..Code:Any city Or on,,
$tri which mquima a permit to consam,4 Aller.improve,demobh,or repair my restructure
_itr^ prior Or its issuance.also requires the applicant for such permit o rile a signed statement
that k is licensed paavaet to the prowiekns of the cmOreemrs Lismmc Law(Chapter 9 Sq.Ft.Floor Area Valuation
�2 (cemmenelegwithsecdanla0)nf0ivismn3artheBasisassmaPmrewionscode)m $1700
.5$ mat W be enempt theaafrom And me basis for the alleged assumption,Any violation of
Section 7031.5 by arty applicant fora permit subjects da applicant to a civil penalty ofNumber Occupancy Type
not mm➢than five hundred dellanea).(s3163 9 0 0 3 :W1
❑Lasawncr.the the
shrome,Is 1amende wimwagaaaevrok c .Bonnday.
will x the wont,and du[tenure arot amended Law du for laic(Sec.]014,Busirm
Ana Property who
W taxi The Dmaxmrs and
Law sae,Out Apply f rt owns Of Required Inspections
own enywho WBaamed that en improvements
me muchwded!orselfoatMugh his
owns employes,provided that such improvements in not can fc aro@ted far owmcL
however.the building or improvement
proving
sold within one year or comm a for me awucr-
builder will Nw the Wrdcn of proving that bo did trot Wild or improve for purpose of
wk.).
D 1,u owner of the property me euluuvcly contwning whir licensed anuscras to
construct the project(Sec.]OCd.limmunes met Professions Cox:)M Conuacmrs U,
«••-law docs not apply m an owner of property who builms or improves them cit,ma
who contracts far such projects wire a anwctuK.)licensed pmso+m m da Covvanors
L'came Law.
D hamesemptmdn See .B&PCfmmism%--
uc Dam
WORKERS COMPENSATION DECLARATION
1 hereby affirm under Natty of perjury,one of the following decleaxns:
sa 1 ham and provided
for by
a Cion 37 a of renunt Cods.
for WarkMs Comf the
ration,ss proh thi(pe by Ss bro 3]a of do IabWr Cax.(car the perfaamvna of Vc
amt for which this permit u iaaed.
D I have std will maintain Workers Compensation Inssvante,as required by Semon
3810 of me lsborcode.for the parfamtance car Use wet for which code permit is i--
My Workcrnsau�m-ym�II.� cc armor and pull ,be ye' ��`I ,].�
Cartier. cls�•Y�—
Policy Na.: �'t/ 1fO0/ p / /
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
r hasomfim need not be completed If tW permit is foram hundred dollars($ia)
or less)
I comity mat in the performance of the work for which this permit is issued.I shall not
cmploy anyperean in any manner an as to biome subject to the Wmiumn'Compensamed
Laws of California Due
Applicant
NOTICE TO APPLICANT.IL aMr making this Certificate of Eatontown,you should
became lublesa or the Workers Compensation provisions of da Isbm Code,you mss
.,O forthwith comply with such provisions or this permit shall x deemed mated.
z
tZI CONSTRUCTION LENDING AGENCY
[-+.�. 1 hcmby arm that,dam is a comrucdon lending agency for me perfwmancc of
the wmrk for which this permit Is issued(Sec.309],Civ.C)
Q Lenders Name
Z:)z =.Addmss
J 0 1 comfy that 1 have read We applieuim and tram most the above mir mnafim is
D.P correct.l agree to comply with all city And county oNi.and some len relating Or
0 V Wilding construction.And hereby authanna repsesenudses of this city to cnw upon da
r 0. Above-mcomered property for impamion purposes
(We)Agree to vve.indemnify and keep harmless the City of Cupenim against
„Fyt, tabiLlmajudgments.coos and expeeaes which may in any way came egaustaud City
CJ Z in consequence of the 1.6. >a permit.
^' APPLICANT UNDE S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
siimmmarAppliantson�mDate DaRe-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tic applicant or future Wilding eceupantuom m handle berANoa material
deBnod by the Cupertino Municipal ode.Chapter 9.12,ani me Health and Safety
de.section zss32(+>" All roofs shall be inspected prior to any roofing material being installed.
[:)Y. o
Will the epplkmt nr moue buil o spam lila AL
or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit nes sNna air eanuminmts fncd by me Bay AL Air Que ily Management all new materials for inspection.
Diss nes
DYes Nu
I hue mad mehawrdmsnu Hri mquimmcn rChapmr6.95oftheCshfor-
nu Halm&Safety Cosc.SectimsuX)5,25533 and 25534.1 urWcnuM thelifthe buibli
does rot currently have•mount this it unobility m notify da anLpNt of the
requlamentawle Eehalt pd., facmBaley�yemmey`b Signature of Applicant Date
/� // /
or lir mthorimd agent Dam All roof coverings to be Class'%¢"or better
Own
• CITY OF CUPERTINO
4 ITEMS OF 12 PERMIT RECEIPT OPERATOR: suew
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 31639003 . 00
DATE ISSUED. . . . . . . : 10/17/2008
RECEIPT #. . . . . . . . . : BS000006379
REFERENCE ID # . . . : 08100101
SITE ADDRESS . . . . . : 20195 NORTHGLEN SQ
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . . `
OWNER . . . . . . . . . . . . : JASON CHANG
ADDRESS . . . . . . . . . . : 20195 NORTHGLEN SQ
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : EDDIE NALLEY
CONTRACTOR . . . . . . . : LEONCE ROUX LIC # 26850
COMPANY . . . . . . . . . . : AFFORDABLE WATER HEATERS &
ADDRESS . . . . . . . . . . : 24707 RAILROAD AVE
CITY/STATE/ZIP . . . : SANTA CLARITA, CA 91321
• TELEPHONE . . . . . . . . : (661) 259-7131
FEE ID UNIT , QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------ ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 1, 700. 00 0 .50 0 . 00 0. 50 0 . 00
1PPERMITFE FLAT RATE 1. 00 40 .79 0 . 00 40. 79 0 . 00
1PRWHEATR UNITS 1 . 00 24 .48 0 . 00 24 .48 0 .00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40. 79 0 . 00
TOTAL PERMIT 106 . 56 0 . 00 106 . 56 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 319 . 68 MC
---------------
TOTAL RECEIPT 319. 68
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ----------- ----------
-------- ----------------------------
518 WATER HEATER
•
f� Community Development
m i 10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS:Z O`� ( PERMIT # &,) r I
OWNER'S NAME: Sl•1sow C PHONE # pA- 2y2- 767 -4-
GENERAL CONTRACTOR: AFr(4DAG FAX #
I am not using any subcontractors: /U //7 /1
ig ature 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
alboWATER HEATER
41cUP� TINO PERMIT APPLICATION FORM
APN # 3 / 3 9003 oD Date:`0 r 1 r1 I o Y
Building Address:
�?- 1C, s— 40r4C> 1� � s
Owner's Name: Phone #:
Contractor: 1 Phone #:
AC—ForOo4gI� WaL✓ � d ✓
Fax #:
Cupertino Business License #: Contractor State License #:
� X736 �
Contact: r Phone #:
ca
Fax #:
Building Permit Info:
Bld ❑ Elect Plumb �— Mech 0�
Residential ❑� Commercial ❑
Job Description:
t-(C) (�A liv<sj r�ti-�dl—✓
A
Strapped On Platform Bonded Er New Location ❑ Replacement ❑
Valuation (cost of project):
Io
Project Size: Express Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to
the application or if applicable, include in plan set & the sheet index.
Green Buildin Points achieved:
Revised 6/16/08
CITY OF CUPERTINO
� `' WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCWHEATR Commercial Water B PCWHEATR
HeaterNent
1BSEISMICOM Seismic Commercial B
1PRWHEATR Residential Water B PRWHEATR
HeaterNent
' 1BSEISMICRE Seismic Residential B
I 1PPERMITFEE Plumbing Permit P
1TRAVDOC Travel & B
Documentation
1BUSLIC Business License B