08110063 CITY OF CUPERTINO
BUILDING DIVISION PERNUT �jC0NTRACTORINF0RA r�TION
-ter' w-� �s.=�..>' .
BUILDING ADDRESS: _ PERMIT NO.
19317 SAKURA WAY TBD - TO BE DET RMI
OWNER'S NAME: PERMrr ISSUE DATE
ONE: A 0. 9 9 8 CONTROL N0.
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
0 0 0 0
uwp LICENSED CONTRACTOR'SDECLARATION irJ Job Description
rd 1 hereby alarm that l for,lien W under provisions of CWplcr 9(commencing .30
with Section]IXIU)af Divisi 3o(tW Budneas rd Prof vCode.ambo Yliceve'
"_�H �nrallrmce=ndarcecv � �ix 40 GAL WATR HEATER REPLCMNT NOTE: MILLS,
MECHANICAL
r Date Covuvsar
W ARCHITECTS DECURATIO
7 IUMcnumlmyplvushallbeused upublic rrenNs PD FOR BUS LIC $110 . 00 11/1$/$
Reeved Pmrcisianel
3 OWNER-BUILDER DECLARATION
G
5i I hereby affirm that 1 am exempt from the Contractor's License Law for the
COO following mason.(Section 7101.5.Business and Profeuioed Cade:Any city at county
m which requlry a permit In cal.alter.improv,demolish,ns repair any awctuhe
Z y prior In its ismanee.also mpunto the applicant forsueh permit m Ole a signed statement
pp that he is licensed pursuml1.th,prmishentthe Contractors LicenseLaw(Chapter 9 Sq.Ft.Floor Area Valuation
y�s (commencingwith Sation7000)of Divlsion3afthe BusinmmdProfetoians Cadc)or 900
s Iden M u exempt therefrom and the basis for the alleged assumption.Any violation of
Section 701.5 by try,applicant for a permit subjects the applicant to a civil penally of APN Number Occupancy Type
trot roam Who Ew hundred dallare(s5=. 37503010. 00 -
❑1,so ownas of the Property.or my amploytta with wgv u their sale compensation,
wee do the week.and Neswctmve u not intended or affected for sate(Sec.7(111,Business Required Inspections
asad Professions Cade Tie ConvaetoYs Liana ownere ns law does Out apply m an Of q p
M,ny who basilliorireprom Wvmn,aM whodossuch while himvJrm d1rougb his
awn employees,provided that each improvements am not int-Mrd coffered foal,ff. '
hvxeser,cite building or impmveman is cold within One yeas of completion.the owner-
W ilt er wilt base the,bus has of proving Wt Iter did.al build or improve for purpose of
sale.).
❑1.as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.]0a4,Business and Profesiav Cade:)The Caatncer's V.
cava law dos not apply to an owner of property who Wilds or improves theman.and,
who carman for such pmjecu with acorn ictor(s)licensed pursuant to Bin Canuacuses
License Law.
I am exempt under Sec. .B d:P C fee Nis mason
Owner Data
WORKERS COMPENSATION DECLARATION
I beaeby air=under penalty of perjury aro of the following dedurationi
1 have and will maintain a Cen;note of Covent to calf-imum far Worker's Compco-
on.u provided fee by Seedon 3700 of the Labor Code.for the performance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as raptured by Section
3700 of de labor Code,for the performance of de work for which mus permit u issued.
My Worker's Compensation buunue canis and Policy number
Cartier. ' Policy No.:
—CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
mus section oed Trot bocompleud tides permit a Totemic hundred dollen($100)
or less)
I carry that in me peformaroc of the work for which this permit is hared.l"I no
em I an urformraordle Othe rob I se delyorkcrs�ompesny,ro '
Law 0 Calvf0arrrYDate 1/•-/X"
Applionr er,'
NC7TICETO APP LIGNi nprCeNficate of EaaW,CdYoushouN
.J Oboomer comp y the Worh Pro Comas Of thin pvvit ions of the n=o Cod,you masa
forthwith comply with maim Provisional or mu permit shall W deemeC mwked.
"7 y CONSTRUCTION LENDING AGENCY
E.m 1 hereby of irm that mem is.covuuelino lending agency for the performance of
ry' > the work for which No permit is issued(Sec.3097,Civ.C.)
GA lender's Name
z Lender's Addrw
U 1 cenirY that I have read this application urd sure met the eWw informed..it
tl. H carer l agree m comply with all city and county ordinances and shote laws miming to
-�U Wilding connotation.and hereby authories represcnutiws ofthin city to enter upon time
above-mcntiood pmpeny for ivpectlon pum.
f"gy (We)agree to sale,indemnify and Incept humleu the City Of Cupenina against
Iia dilitica,judgmcno.costo and caperuu which may in my way arena against said City
U to corlYptcnee of the swung of this permit.
APPLIC NT UNDER ANDS///555[[[��fDyyyll/ILL C,7�/PLY WITH ALL NON-POINT Issued by: Date
SOU REGUI.a S.
O Re-roofs �----
SignatumofApplian OARData
u
US MATERIALS DISCLOSURE Type of Roof
Will chat nCuprtcar future building Ch nor
handle hvudovmaseriai
as de0rmd by Ne Cupen;mro Munici I Cade.Chapmr 9.12,and Ore Hcalm and Safety
Code.Semon 25532(a)y All roofs shall be inspected prior to any roofing material being installed.
❑Yv No
Will me,applicant car fuwm b
In
occupant era cyuipmcnI car devices which If a roof is installed without first obtaining an inspection,I agree to remove
R harardnv air contaminants Rncd by the Bay Arta Air Quality Management all new materials for inspection.
at ice]
Y. No
I hew read the haramdmto materials mph Wments under Chapter 6.95 ofthe Califor.
nu Health d:Safety Cade Swots 25505.25533 and 25534,I undcnuM mat ifthe ddkting
dery col oasis haw a dot it u m respanci '1'Y m natifY th accuprt of the
regNre whichmaa lar car re.teof Signature of Applicant Date
o erorrma r=d con Dae All roof coverings to be Class'/¢"or better
CITY OF CUPERTINO
S 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37503010 . 00
DATE ISSUED. . . . . . . : 11/18/2008
RECEIPT #. . . . . . . . . : BS000006638
REFERENCE ID # . . . : 08110063
SITE ADDRESS . . . . . : 19317 SAKURA WAY
SUBDIVISION . . . . . . .
' CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : SPENCER THOMAS A AND HILARY H
ADDRESS . . . . . . . . . . : 19317 'SAKURA WAY
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : GARY MILLS
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . .
TELEPHONE . . . . . . . . :
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- -------- ---
1BSEISMICR VALUATION 900 . 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
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 216 . 56 AMEX
---------------
TOTAL RECEIPT 216 . 56
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------
518 WATER HEATER
•
09
SCD, CITY OF CUPERTINO
WATER HEATER
• CUPEkTINO PERMIT APPLICATION FORM
APN # 2-7 3 O / 0 ,
3 v Date.` � \ l � Do
Building Address: t9317 \
KV ► W
Owner's Name: Phone #:V5 930 —17k
0*NkS fens -Pwyc4qlu
Contractor: M, Phone #: 510-
Fax #:
Cupertino Business License #: Contractor State License #:
c64W!5
Contact: Phone #: v j0 CrA5(p
W6 or �Ct1r �i��b-� "Fax #: S`70 7 L7V Je3 -I
Building Perrhit Info:. A-e�
Bldg ❑ Elect Plumb Mech El�
Residential Commercial ❑
Job Description:
Strapped On Platform Bonded ` New Location ❑ Replacement
Valuation (cost of 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