08110029CITY OF CUPERTINO
BUILDING DIVISION PE
COl-VTItAGTOR�IIVI''ORMATO-Tarr'
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BUILDING ADDRESS:
PERMIT NO.
10660 JOHNSON AVE
RPTTFR WATER HRATERS
nplinn2q'
OWNER'S NAME:
PERMIT ISSUE DA'Z'E
5
CONTROL NO.
408)250-6672
ARCHITECDENGINEER:
BUILDING PERMIT INFO
BLDGEIEC? PLUMB MECH
=1 � 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
op
1 am licend udenr provisions of Chapter 9 (rnmmoncing
I hereby affirm thisI a
wish Section 7000) of Division Sof the Business and Profaaians Coda, and my license is
infull foramdafiam
WATER HEATER INSTLTN
uaun Clan Lk..
Dam Contrxmr
ARCHITECTS DECLARATION
1 undertend my plans shall be used As Public records
Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby alum that 1 am stamps from the, Com ones Lkenm Law for dm
following mu mn. (Section 7031.5, Business and Profession Cora: Any city or county
which requires A permit m COns &Iter. improve. demolish, or repair my structure
prier 0 its issuance. also aquims dbc applicant for such permit m frk. sigad statement
Sq. Ft. Floor Area
Valuation
dean the is licensed purmxntm de provision of the Commutes License Law (Chapter 9
(commencing with Section 7000) of Division 3 cram Buaina.atd Profession Cade) or
$1000
that Ins is exempt themfmm and the buts for the a1kgad eaemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applkanuo a civil penalty of
trot mom date frw Wndrtd d.1hom 451X0.
37528022
❑ 1. u ower of tle pmpvty. a mY uoPloyea wRh wage az the'v tele compewton,
.00
Required Inspections
win m the work, and the suu.dtrre ts mlintended cr oaeted fersalo (See. T0s4, Business
and Pofessimes Cade: The Comlxcmrs License law does net apply An An owner of
property who builds er impmws thereon, and who does such wok himself err through his
awn cmPloyen. provided fi usuch impo semmts art not intended oroRered forsals. If.
however, Ne building or improvement is mid within ore year of completion. the owner.
builder will have the burden of moving shat he did not Mid Or improve for purpose of
sok.).
0 1. As owner or the property. Am exclusively contracting wits Beemand canhmdam In
consuuct th unimtt (See 70 . Business mad Professions Cade:) Than Ccotractoes Li.
Oman law domag not apply on An owner M property who builds or improves themon. and
who coronets, for such pmjccu with a enntraatora) licensed pursuant m de Conuaemis'
r
License law.
❑lamap �nda,�SM, B h P�for this
/reason
-
rC�
Owner a•r -- Data 1L
WORKERSCOMPENSATIONDECIARATION .
I hereby aQum under penalty of pe0ury arc of the following decluuiare
and will of Werrmancarnpen-
satthaw
Salon 31011 a( the labor Code, far Use performance of the
As for37M Cols,a
for
for
wentf
wade for which Nis permit is iazeed.
mi
0 1 bow and will maintain Workers Compnnsuion InsrumA az requited by Section
3700 ofthe later Colo. for the puformmce ofthe wort ferwhlch this permit Is issued.
'
My Winkds Cnmpaamtion Insurance artier W Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This segirn and nottcconpleed ifft crook is forams hundred donan (SIM)
Or loss)
I certify that in the parr.. of the work for which data permit is issued I dealt rot
employ any person in my amens: p u�q becomembjecl m Ne Workcn' Camprnution
laws of Cal"fp iy D Lir - r^O aaXX,,
Applicros far 2 . ,Yr�i. m..i �_✓
NDDCE TO APPLICANT. If, after making this CmtEcae of Exemption, you should
Weome subjm he the WarhYs Compcaadon provisions of de Labor Cole you most
forthwith comply with Arch provisions or this permit mal k dcomrd revolted.
CONSTRUCTION LENDING AGENCY
1 hereby AM. Wt there is A euatroctinn knding.gumy for the performance of
' Na work for which shts permit is issued (Sec. Som, Ch,, C.)
'
Lender's Name
lenders Address
1 certify that I have rod shin application and sort this she shove Worreation is
'
' coved 1 agree m comply wide All city and county Ordinances And start Ire missing m
Wilding conmumion, and hereby mthoaim reprtscoetives of this city to enter upon mho
above-mentioned property fee inspection purposes.
(We) agme to taw, indemnify and keep harmleaz the City of Cupertino against
j liabilities. judgments. costs and expenses which may in my waymcme against mid City
v in consequence of the jrmting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AIS. NON-POINT
o
Issued by: Date II � � V
6&-
SOURq REGULATIONS.
-
Re-roofs
n.yf.•, 1-7-0$
Signamrtof AppliceDa m
HAZARDOUS MATERIALS DISCLOSURE
DO
Type of Roof
Will thea or future Wilding aahaptr9,1 handle hmarmm maeriai
As de0ned by the Cupertino MuniriWl Code. Chapter 9.12, and sire Hea1N and Safety
Cupertino .
Com. Suction 25532(x)1 -
All roofs shall be inspected prior to any roofing material being installed.
0Ya W.
If'a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding Occupant Me equipment or devices which
Oil hmadous air contaminants As dmhad by the Bay Area Air Quality Management
all new materials for inspection.
Oistrlctl
C Ya [�a
1 have mad the ha mums materials mWiremrnu under Chaper&95 of Ne Califer.
.is He.]"SdmyCOde, Srnfw 25M. 25533 atv125534.1 umlorrand dm if de Wilding
don not currently have a tenses, this it is my responsibility An entry dm aaupml of de
nexitomernams which noun "Me/}prrig/p/�u mama ora certBc.mof Oscupruy.a
Signature of Applicant Date
All roof coverings to be Class /¢ or better
Dam
Owner nrmthmi.dagent
• 4 ITEMS OF 4
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ......... 37528022.00
DATE ISSUED.......: 11/07/2008
RECEIPT #.........: BS000006568
REFERENCE ID # ...: 08110029
SITE ADDRESS .....: 10660 JOHNSON AVE
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: CHRISTINE HANSEN
ADDRESS ..........: 10660 JOHNSON AVE
CITY/STATE/ZIP ....: CUPERTINO, CA 95014
OPERATOR: patg
COPY # : 1
RECEIVED FROM CHRISTINE I HANSEN
CONTRACTOR .......: FRANS CARTWRIGHT LIC # 26514
COMPANY ..........: BETTER WATER HEATERS
ADDRESS ..........: 351 FALCATO DR
CITY/STATE/ZIP ...: MILIPITAS, CA 95035
TELEPHONE ........: (408)250-6672
• FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL
1BSEISMICR
VALUATION
1,000.00
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
-----------------
CREDIT CARD
TOTAL RECEIPT :
AMOUNT
---------------
106.56
---------------
106.56
VOICE ID DESCRIPTION
-------- ----------------------------
518 WATER HEATER
REFERENCE NUMBER
--------------------
AMEX
VOICE ID DESCRIPTION
CITY OF CUPERTINO
6a,' WATER HEATER
OF
•CUPEkTINO PERMIT APPLICATION FORM
r
L_
APN #
&-)5a ?oas. 0
Date:
lo.- 30 -
Building Address:
�p Gia J—flht.�so�%
Owner's Name:
Phone #:
q�vlrl-sa-�-
Contractor:
Phone #: LI p g _ a[-50 - (o%A
d it w�1r-s
Fax #:
Cupertino Business License #:
Contractor State License #:
.L�6/L/
°o)$Sl q
Contact:
Phone #: yb 8_Co-�lo
rmo-s C*3+LJVll
Fax #:
Building Permit Info:
Bldg Elect
Plumb' y- Mech
Residential
Commercial
Commercial ❑
Job Description:
01\J
Strapped ❑ On Platform ❑ Bonded
❑ New Location ❑ Replacement
Valuation (cost of project): 4 --
Project
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
GGA. CITY OF CUPERTINO
WATER HEATER
OF
CUPER,TINO PERMIT APPLICATION FORM
Quantity
Fee ID
Fee Description
Fee
Group
Permit Type
1PCWHEATR
Commercial Water
HeaterNent
B
PCWHEATR
1BSEISMICOM
Seismic Commercial
B
1PRWHEATR
Residential Water
HeaterNent
B
PRWHEATR
r
1BSEISMICRE
Seismic Residential
B
1PPERMITFEE
Plumbing Permit
P
1TRAVDOC
Travel &
Documentation
B
1BUSLIC
Business License
B
0
0