08100103 CITY OFCUPERTINO
BUILDING DIVISION PERMIT
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DUIL21NG ADDRESS: PERMIT NO.
G1119 BEAVEN DR AFFORDABLE WATER HEATERS & 08100103.
HER'S NAME: Fii ISSUE DATE
HAWKINS SAMUEL R AND JOANN L 24707 RAILROAD AVE 10/17/2008
PHONE: SANITARY NO. CONTROL NO.
(661) 259-7131
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
uo� LICENSED CONTRACTOR'S DECLARATION Job Description
a
ZC 1 busby affirm Nat 1 uv li ft Bu ruler provisoes of Clupmr 9(wmmeass is p
<L+ wiNSecGon]IXMl),fDivision3ofOmBupnusandRofeuiouCode andmyl&ens is REPLACE 40 GALLON WATER HEATER
bfull rmm.an
Ll ucemea L.c.g� .
q Das O f
ARCHITECTS
TION 2Y
e 7W As sudlb use DECLARATION
e W< land cmund my plans shell he used u public rceoNs
ILG� Licensed Professional
OWNER-BUILDER DECLARATION
a 1 hereby aRrm that I am exempt from the Contractor's License law for the
ip o following reason.(Section 710 0.5,Business and Pmfemior Code:Any city m county
$ which requires a permit on construct,almr,impmw.dcom ish.or repair any On lure
prior N its lstuance.also mq,IR,Ne applicant for such permit to Ek a signed cuumment
that he in licensed pursuant o the provisiom of the Contractor's Liame Law(Clupter 9 Sq.Ft.Floor Area $ Valuation
(conowneing with Section 70M)of Division 3 of the Business and Promum mCode)or 1800
r3
that he u attempt themfmm and the basis for the alleged exemption.Any violation of
Section 7031.5 by a"applicant for a permit mbjccu the applicant to a civil penalty of Number Occupancy Type
not more utast five hundred dollars($500). 3 2 6 4 7 0 5 7 !V(lV
I,u owner of Ne ptopeny,a my emPlvycca with wage u Ne'tr ttl<compewtion,
will do the were.and the structure is not intended ormfrered for sale(Sec.7014,Business
and Ptoresdom er:The Coneacmw r's License laones W1 apply m an owner of Required Inspections
property who builds or impovesthcmon,and whodousuchwohhimslforNmogh his
own employees.pmWded that such improwmenu ace not intended or offered for sale LL
however,the wilding Or imp.ve.anI u sold within one year of completion,the swam.
Wilder will have the Wrden of proving that he did not build or improve far pure¢of
sale.).
❑1.as owner of the propenY•am amluaiwly contracting with licensed contracmes m
cortttmet the project(Sea.70x4.Business and Profusions,Code:)The Contractor's U.
come law does not apply at an owner of property who builds or impm ms thereon.and.
who contmcu for such projects with a edromet r(s)licensed pumant to the Conuacmfs
License Law.
Iamaemptunder See .BkPCfarthismuon
''vnerDECL RDam
WORKER'S COMPENSATIONATION
1 herby affirm under p:naity of perjury.of the(allowing deelar mm:
1 Nve,nd will mvnuin a Cenifiate of Concent m self-inaum for Workers C°mpcn-
smon,u pmvimd for by Section 3700 of the Labor Code,far the performance of de
wart for which this Permit is issued.
1 have and will maintain Workers Compcmatim Imumnce,as required by Section
3700.!the Labor Code,for Ne per(ormancc of Ne vert for which Nu permit is issued.
My Workers C°mp�e/IpsafuOn Laur=a artier aM 1"c"number am: _
Camer.�tw'rY Y� Poliry No. ��rrII�(6 7 4
CERTIFICATE OF E)(EMPDON FROM WORKERS'
COMPENSATION INSURANCE
mus median need mit he conpkstl if the permit is forme,hundred mdan(SIM)
of less.)
1«rify that Is Ne performance of the work for which this Permit u Wand.I dull.1
employ any pc.n in any m=neem u to hecome subject m the Wossri Compenamon
Laws of Caliro wn.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Ccnif ate of Exemption,you should
become subject in the Worker's Compensation pronsiom of Ire labor Code you mus -
O fmMwith comply with such PfGVWOm or this permit shall k Licensed!revoked.
z y CONSTRUCTION LENDING AGENCY
[—n 1 hereby affirm that there Is a comuuctinn Lending agency for the performance of
CC r�-r the wash for which this permit is Wood(Sec.3(197,Civ,C.)
a0 Lender's Name ,
z Landers Add.
U O 1 every that I haw rw this application am sum tw the above Wom mon is
1, H cornet I agree to comply with all city and county Ordinances and sum laws missing to
0U building convection.and hereby authorise mpresnutives of this city to enter upon the
r wve
a -mentimcd property for impecpurposes.onpurposes.W
W (We)agree to...indemnify and keep harmless Ne City of Captor.agdmt
P.ml"i fn liabilities,jWgmenu,emu=dupenxawhich ma,,n=y veiny �t said City n
in comequcrtce of ting of this Permit �j
F-m APPLICA DERSTANDS AND WILL CO WITH ALL NON-POINT Issued by: Date (�
SOU REGULATI
Re-roofs
Signatureof Ap on or Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof ,
Will the applicant Or future Wilding omrp=t sums or handle hvardous material
defined by the Cupenin°Municipal .Chapter 9.11.and the Holds and Safety
.sect;°m z5531(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑k. o
Will Nc applic=t or Tamm wilding n1 utt equipment or devise which If a roof is installed without first obtaining an inspection,I agree to remove
emit hayarmas air COMPO as defi y tie Bay A aAir Gustily Management all new materials for inspection.
District?
❑Yes u
I have mad the huatooes maerialsrequiremcnen under Chapter6.95 ofthe Califor-
nuHca1N&SafmyC 'om155115.25533 and 35534.1 urdcnund NsffNe wilding
Jan not curse w 5 tenant that
it b my rap ss m notify de scup=t of Ne
require wbc etpriormhad aComfiateofOccupancy. Signature of Applicant Date
Owner or aumaristl agent— Date- All roof coverings to be Class'W'or better
• CITY OF CUPERTINO
4 ITEMS OF 12 PERMIT RECEIPT OPERATOR: suew
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 32647057 . 00
DATE ISSUED. . . . . . . : 10/17/2008
RECEIPT #. . . . . . . . . : BS000006379
REFERENCE ID # . . . : 08100103
SITE ADDRESS . . . . . : 21719 BEAVEN DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : HAWKINS SAMUEL R AND JOANN L
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, - 95014-1220
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, 800 . 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
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
----------- ---------
----------------------------
518 WATER HEATER
•
� CITY OF CUPERTINO
� Ela' WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
c/) f10 le33
APN # 3 / Date:
cP OS� !T� /b . 7 /cff
Building Address:
Owner's Name: Phone #:
Jo\p"T-JMA' �Aa pkk-"s �-{ oy— zs 3 — 05-
Contractor:
sContractor: Phone #: 6
Fax #: tot;
Cupertino Business License #: Contractor State License #:
Contact: Phone #: bbl 2t5— ��3
Fax #:loco ( - 255--`1 f5 G
Building Permit Info:
Bldg- ❑ Elect ❑ Plumb,' Mech [�
Residential [ Commercial ❑
Job Description:
RcQlccc .,jJ ✓ 6y
Strapped On Platform EJ Bonded Er New Location ❑ Replacement
Valuation (cost of project):
� <�OU
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 Building Points achieved: —
Revised 6/16/08
1 CITY OF CUPERTINO
WATER HEATER
OF
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
I 1BSEISMICRE Seismic Residential B
1PPERMITFEE Plumbing Permit P
1 1TRAVDOC Travel & B
Documentation
1BUSLIC Business License B