08110002 CITY OF CUPERTINO
BUILDI cYIVL'�N PERNIIT CONT9ACTORINFU'RMATION .
��
BUILDING ADDRESS: PERMIT N0,
20363 CLIFDEN WAY ALL VALLEY PL
OWNER'S NAME: PBRNUT ISSUE DATE
ONE: A CONTROL NO.
(510) 376-4816
ARCHITECTENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB - MECH
uOp LICENSED COMRACr0WS DECLARATION W Job Description
�m 1 mmby affirm Nat I am licenaed under pmviuona of Chapter 9(commencing P
W MSection 7")of Division 3 of thm Business and Profeudous Code,Nd my license
noh'n in fun some and a(" tit asp WATER HEATER REPLCMENT
Lies.Cl Lk.•
=p Dam Conuauor
e WW77 ARCHITECTS DECLARATION
y U 1 understand my platy shall M used u public records -
Dieu
o Licensed Professional
OWNER-BUILDER DECLARATION
i yI hemby M.that I at exempt from the Contractors License Low for the
p 0 following mown.(Sectio 70313,Business and Profeuimns Cade:Any city Or only
s m E! which rectum,•permit to construct,situ.improve,demolish,or m*r any structure
un Prior m it issuance.also reeuiru the applicant for such permit m FIV a signed summa,
0< that heis licensed pursuant tothe provisions ofthe Contncmr,IJcenseLaw(chapter 9 Sq.Ft.Floor Area Valuation
0 (commencing with Section 7000)of Division 3 of dec Business and Professions Code)or
y $ that he is exempt therefrom and to basis for the alleged exemption.Any violation of $700
Section 7031.5 by airy applicant fora permit subject Che applicant to a civil penally of APN Number e Occu anT
ilmmm than Ove hundred dallan(M), 36937009 . 00 Occupancy
Type
❑I,u awns a(tlie pmpmty,m my eroplaym wird wages u they tele campensatiw,
will do thewo&-and them coma Ono,intendedaraffened Imsale(Sec.70/4.Business
and ProfCalow Code:The Cm uacwrs Lt.=Law don co,apply e a owner of Required Inspections
property who builds m i mprovcs thereon,and who data such work himself or through his
own employee,proMded that such improvemau art a,intended mnRemd fmsale If.
howmv,the building or improvement is aid within arm year of impletion,the mam,
Wilder will have the burden of proving that he did an build err impovc for purpose of
sale.).
0 1,as owm of the property,me eaGwivelY conmusing wird liensed cora scala b
consumer the project(See 7044.Business and Professors Codue)The Coauxtora U-
.law dons ooh apply m an owm of properly who builds of improve thereon.and,
who conuacu for such projects with a canuacmr(s)B¢ned Formal to Camecmrs
License Law.
❑Iomaempunder See .BBPCfmthisreuon
Owner Dam
WORKERS COMPENSATION DECLARATION
I hereby air=under Mousy of perjury one of the fallowing declmatmer
ham and will malnuin•Cerffusu of Come nuo mlFiwum for Worker's Compete
n,as provided for by Section 3700 of the labor Code,for Ne prformarae of the
mk for which this permit is issued.
❑1 have ad will mumu.Workers Compensation I.,as required by Section
3700 of the labar Code.for the performance of the work for which this Permit is Issued.
My WorkersCom{p��".Inwnn¢emirs and Policy number a rt: rJ
.
Cartier. oft)C- J
Policy No.: hq 7 DI b
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE ,
fids seal.need ret W corepkmA alube permit is for.hundred doll.(SIM)
mks,)
1 anify that in the perform.of the work for which this permit is iaucd,l"I not
employ any person in any manderso as to become subject to the Workers'Compensation
Lows of califomis.Dae
Applicant
NOTICE TO APPLICANT.IL after making this Certifies¢of Exemption.you should -
become subject to Ne Workers compensation pvimma of the lahar Cade.you mut
.J O forthwith comply with such provisions or this permit shall be dimcd k.d.
z ti CONSTRUCTION LENDING AGENCY
[-a IherebyOrm tut Vert isacd(See(Sec..nnlending agcay for tic prfurmacouf
ani.moi to tyre fur which this permit is Rued J097,Civ.C.)
Q Lenders Name
D Z Leaders Address
U O 1 certify that I have and tit,app iew..arta sue thou the abovc infamous.is '
l�P cartes i agree In imply with all city outd county ardinanas and sok laws relating he
0U Wilding cowmxtion.and hereby alariec mpnesatativcS of this City m ams upon the
W abme-mendmcd property,for inspection purposes
(We)agree m save,indwre fy and keep harmless the City of Cupertino against
,,n Iiabilites,judgments.cost,and expenses,which may in my way gime agunat acid City
U Z in consequence of the{renting of t iS pemniL y J —^
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date rJ
SOURCERL
C n�oalot5 Re-roofs
Sig...of Applic mUConlracwr D96
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupalouure or had heaallow material
as dell ed by the Cupertino Municipal Code,Chapter 9.13,ad due Health ad Safety
Cade,section 35531(a)7 a All roofs shall be inspected prior to any roofing material being installed.
C]Y. e<
Will the applicant or future building oxupat tae Wuipment or dcvim which If a roof is installed without first obtaining an inspection,I agree to remove
"t haaardnus air conumiwnu as defined by the Bay Area Air Quality Management all new materials for inspection,
ct7
pyo L?fr
I ham mal the ha»rdousmamriais rtquirem mu under ChaPerd.95 ofthe Califon,
ma Hrahhh Safnycode.Savoy M505.25533 md25534.1unduYvm t adthe Wilding
dm Out currently have a mnsns Nm i,is my responsibility to notify the occupal of the
uremcntw mel Rata ora Cm f,.W'foc Signature of Applicant Date
req pct
f j X03 o All roof coverings to be Class'%},'or better
Ownermmthomed agcm am' '
r �
CITY OF CUPERTINO
• 5 ITEMS OF 9 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36937009 . 00
DATE ISSUED. . . . . . . : 11/03/2008
RECEIPT #. . . . . . . . . : BS000006526
REFERENCE ID # . . . : 08110002
SITE ADDRESS . . . . . : 20363 CLIFDEN WAY
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . ,
OWNER . . . . . . . . . . . . : TSUKAMOTO MINORU AND KYOKO
ADDRESS . . . . . . . . . . : 20363 CLIFDEN WAY
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4460
RECEIVED FROM . . . . : ALL VALLEY PLUMBING
CONTRACTOR . . . . . . . : MARY SANDBRINK LIC # 23015
COMPANY . . . . . . . . . . : ALL VALLEY PLUMBING
ADDRESS . . . . . . . . . . : 3345 SELDON CT
CITY/STATE/ZIP . . . : FREMONT, CA 94539
TELEPHONE . . . . . . . . : (510) 376-4816
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 700 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1BUSLIC FLAT RATE 1. 00 110 . 00 0 . 00 110 . 00 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 216 . 56 0 . 00 216 . 56 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
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518 WATER HEATER
•
CITY OF CUPERTINO 0 u�
WATER HEATER
CUPc,r os
ER_TINO PERINTIT �APPLICATION FORM
I Date:
Addre,.s:
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1-ocam-m, Replacement
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-must be coyripleted anti attached to this application.
green ec
Building POill's achieved: