08110040 CITY OF CUPERTINO
BUILDING DIVIS`ONPERMIT t RACTQ,R�TNFORRM," TION
BUILDING ADDRESS: PERMIT NO.
22116 LINDA VISTA PL JUST WATER HEATER
OWNER'S NAME: PERMIT ISSUE DAM
r�fb7rc SXI4ItA O. CONTROL NO.
l
(510) 293-9901
ARCHREC77ENOINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
fop LICENSED CONTRACTOR'S DECLARATION Job DBSCfIpI100
4 Z C 1 hoseby inn Nat 1 am M
Ileecd under provisions of Chides 9(commencing
<tl
with fullto 70M of REFLC WATER HEATER
in ren faux and dreg
i'q 3 Lkave CIw Lie. .
7W
n h p Dab Cons
lARCHITECTS DECLARATION
DECLARATION
1 understand mY Plass shit W used an public reeoNs
JdU
k G Licensed Professional
OWNER-BUILDER DECLARATION
a 1 orehy.(Sero o that 1 1. ucmpt from the Caedones en License Law for the
9 D o following mason.(Scotian 7031.5.L5.Business and ere.de oli Cents:Any city or county
$ which requires a permit m cartaNCl,dter,improve.demnlixh,or repair any Structure
prior m its iuvceabo
n . reqe uirthe applicant for such permit W file a signed sonameni -
< Ilwouslicemed parsunlroNe pmvisime0fthe Canaacmrs Limen Law(Chameng Sq.FL Floor Area Valuation
xH 9 (commen ng with5 ctian 7000)of Div.;an 3 of Nc Busi..d ftfeasiaru Cade)ar $767
Q
59 the he u ath
empt erefrom and the basis for We alleged exemption.Any violation of
Section 7031.5 by any applicant for a pemtil sabi"m the APPltearrt lo a civil Penalty of APN Number Occupancy Type
not more Nan fin hundred dollars($500). 35608010 . 00
❑1,as owner of the property.m my employees with wages as their Ale compevedm,
will do the wort and thcshucusus not intended or offered for sale(Sec.7044.Business Required Inspections
and profession Code The Contractors Li.law dons trot apply b an ownere of q P
pmpenywho buildsmimprow thmmn,andwho does anchored himself rot mogh his
own ampbym,provided dist such impronmmu are not intended maffered Int sale If.
however,the building or Improvement is said within arc year of mmpkuom.the owrcr-
builder win how th burdsn of proving Chat In,did ms build or improve TO,Purpos of
ale J.
❑1,as Caner of the property am exclusively coourmth i with licensed canwnon b
consumes the pmjvl(Sne.7044.Business and Professions Code:)The Commbr's U.
comes Law dais not apply in an owner of property who Wilda or improves tomon,and.
who mnmcn for such pmjecn a ids a mm ant.)licensed pursuant as ds Chummier.
bends,law.
01 sm uwpt underB&P C for thus meso
Dao I I O 08
WORKERS COMPENSATION D RATION
I hereby affirm under patently of perjury One of the,fallowing declarations:
I have rend will maintain•Ca,iifipb ofConscm b Alf-inure for Workers ComPen-
adan.as provided for by Section 3700 of the labor Code.for the performance of tW
wort for which alis permit is named.
1 have and win maintain Waters Comperuauon Inmmoc.as restrained by Section
3700 oldie LaorCade.for the Performance Clothes amt for which this permit is issued.
My Workers Campeouum Wurance Cartier and Policy number are:
Geier. Policy NC.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Lb;sacton need net W completed if iW Permit Is fmone hundred dollen(5100)
or less)
1 Certify that lo the pcdorm sem a the were fm which this Permit is intend.I shall not
employ my pesmn in any maser se an an become abject tithe orke 'Co pewdon
laws of Califumia.Dale
Applicant �-4�
NOTICE
"OAP I.WANT.If,after making this Certificate of Ewmprion,you should
become subject to the Workers Compensation provisions of be tabor Code.you most
0 O forthwith comply with such prevision or this Permit shah In decreed revoked.
zCONSTRUCTION LENDING AGENCY
(~ l hereby aRrm that Nen la s Conwucum lending agency far the parformane of
a > the work for which this permit is iumd(Sa.3097.Civ.C.) '
fA a Lenders Name
DZ Landers Addrea
(�Q I certify that I haw red Ws applicalon and sae as Ne move information u
ty ^. comtt l agrce b comply with
all city and county mdiamm,s and sate laws relating b
.Q CrJ' building construction,and hereby Authorise representatives of this city m enter upon Nc
Lsl shove-mentioned Property fo inspection purpose.
(We)agree to saw.indemnify and keep hmtess the City of Cupertino against
,r, Ilsbilitica,judgmmu.cosuersexpmons which mayln anyway seers againstsaid City — i1
U Z in eanstgvace of de Sooting of this pennil
r-" APPLICANT UNDERSTANDS AND WILL CO PLY WITH ALL NON-POINT Issued by: Date
SOU_!R REGU ITIS -
��� I6a "i
ID/0B Re-roofs
Signeum of AppllcanAZOnuaclor Dam e
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will f applicant or forum Wilding accupean sten.or handle haaardms material
as defined by ton Cupertino Municipal Code,Chapter 9.12.and de Hcalth and Safety
Code.s«tmzsslz(a)7
(3y. NN. All roofs shall be inspected prior to any roofing material being installed.
Will the appreanl or future Wilding«eupant tes,equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
III havasdoa Or cmum;vnu as defined by the Bay Area Air QuaOty Management all new materials for inspection.
sulan
❑Yca %No
1 haw real the hvardousmabrials mqu;mmcnss umkr ChaPmr G95 of Ne Catifm-
nuHwlN&SafctyCCdC,Seetiav 25505,75533 and25534.1 uMcnab daif Che Wilding
docs rot tummy haw a bean.da it is my responsibility m notify the occupant of NC
p
which an b t arbiaAn c e.bartpa�. SignatureofApplicant Date
� [t to Done r „
Owner Or amtharvnd ascot —'Date. All roof coverings to be Class A. or.better
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg ,
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35608010 . 00
DATE ISSUED. . . . . . . : 11/10/2008
RECEIPT # . . . . . . . . . : BS000006585
REFERENCE ID # . . . : 08110040
SITE ADDRESS . . . . . : 22116 LINDA VISTA PL ,
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER GOORVITCH DAVID AND NORMA TRUS
ADDRESS . . . . . . . . . . : 22116 LINDA VISTA PL
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4022
RECEIVED FROM . . . . : DAVID GOORVITCH
CONTRACTOR . . . . . . . : GILROY, JOHN LIC # 15128
COMPANY . . . . . . . . . . : JUST WATER HEATERS INC
ADDRESS . . . . . . . . . . : 3400 INVESTMENT BLVD
CITY/STATE/ZIP . . . : HAYWARD, CA 94545
TELEPHONE . . . . . . . . ('510) 293-9901 n
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
-- --------- ------
1BSEISMICR VALUATION 767 . 00 0 . 50 0 . 00 0 . 50 0 . 00
IPPERMITFE 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
-------------
CREDIT CARD 106 . 56 VISA
---------------
TOTAL RECEIPT 106. 56
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-- ---------------------------- -------- ------
518 WATER HEATER
•
CITY OF CUPERTINO ��`� 0 0
WATER HEATER
OF
•CUPERTINO PERMIT APPLICATION FORM
APN # Date:
08
Building Address:
Owner's Name: Phone #:
DAV D G-oo PwTct4 1�0F - 95 :1 — �o y (
Contractor: rr '' 11 1 Phone #:
Fax #:
Cupertino.Business License #: Contractor State License #:
S� 13.2
Contact: Phone #: _goo - 6 96 - Q90
Fax #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb FZK Mech ❑
Residential ❑ Commercial ❑
Job Description:
Strapped ❑ On Platform ❑ Bonded ❑ New Location ❑ Replacement ❑
Valuation (cost of project): 4 6. 7 0�
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
G� WATER HEATER
ITY OF
CUPEI,TINO PERMIT APPLICATION FORM •
Quantity Fee H) Fee Description Fee Permit Type
Group
IPCWHEATR Commercial Water B PCWHEATR
HeaterNent
1BSEISMICOM Seismic Commercial B.
' 1PRWHEATR Residential Water B PRWHEATR
HeaterNent
1BSEISMICRE Seismic Residential B
1 1 PPERMITFEE Plumbing Permit P
1TRAVDOC Travel & B
Documentation
1BUSLIC Business License B