08120012 CITY OF CUPERTINO 'a €pr✓s1 "' '�` ' " ` ' '`
BUILDING.DIVISION PE �R� 1 ItQ1CTo OINF 6,6�T'
BUILDING ADDRESS: PERMIT NO.
21020 CORY CT FAST WATER HE
OW NEWS NAME: PERMIT ISSUE DATE
NE:
A O. CONTROL N0.
(800) 454-8955
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
.Op LICENSED CONTRACTOR'S DECLARATION
Job Description
rd 1 hereby affirm ttit 1 un lio:pcd umkr provioons arCLpeer 9(commcncWg
with Section May)of Division 3 ofte Budneu W Prolesdona Cede.not my licence is
? N inruBfmcemderfecs RMV/RPLC GAS WATER HEATER
p n Z License Clea Lie.It
p Da¢ Conuacwr
FQ' ARCHITECTS DECLARATION
W U 1 understand my plant"I w need u Public maoNa
n
1
y C n Licenced Ptefumai
tn
5 OWNER-BUILDER DECLARATION
Si I Mreby afro Nal I am exempt from the Contraeux'.License Law for the
y O o following remon.(Section TID 1.5,Business and Rofrsuuv Cade:Any oily m county
K$_ which requires A Permit to convect,alcor,imprtm,demolish,or repair my avuctum
u i y prior W Vu issuance.also requires Ne applipnt fmauch permit to Rlc•signed smkmnnt
E C Nu he is liceneed punnant to to provisions of the conuacmrs U..LA.(Chapmrs Sq.Ft.Floor Area Valuation
yl- (cornmencfngwith Sectorsxemmed N
7000)of Divuim7oftw BuJncn rod professions Code)m 449
y $ Nat he k exempt thneftere basis for Nm
e Alleged eaption My violation of
Section 70713 by any Applicant for a Permit mbjecu the applicant to a civil Penalty of APN Number Occupancy Type
not mew than five hundred doll.(IM. - 35904031 . 00
❑1,u owner of the property,er my employes with wages u Heir sok campewton,
willde Newmk.anddumucheuentinmutedora@reA fonde(Sec.7W,BWmAA Required Inspections
W Procter..Code:The Crum acmfs License Law does Out appy m An owrnm e ns of q P
prepenY who builds or im prtrnm Nunn,and who does such were himulf or though his
own employes,provided Nat such improvemenu are nm inteded Or offered for Attic.R,
boa...the wilding or improvmnent W soM within orc year of mmpleuoo.the owty-
Wilder will haw to burden of pmHng that he did rot Wild or impvw for porpoee of
sakJ.
❑1.u owns of the property am eacinively commeling with licensed convenors to
construct Ne pmjen(Sec.7W.Huainan ad Pmecu t a Code:)The Coeoacraa's U-
ceve law does Out Apply be An owns of property who builds or improm Nemon,and,
who cmtncu forsurth gejeeu with aconuanarts)licensed pmvnnl m ted Cmvanor',
L arta law.
❑lampunphundmsee ,BAPCfor Nismamn
Owrcr Date
WORKER'S COMPENSATION DECLARATION
L bereby of ino under penalty of perjury one of the following dectendome
I in.And wul mamwn A Cerun.w of Covent an aclf-insure fm Werkds Compere
on,n proridd fee by Section 37W of the Labor Code.for the peRemance of the
work for which this permit is bound
❑1 haw and will maintain Workers Compensation Insu,vice,a required by Sectio
7700 of to labor Code,for the Performance of the work for which Nis Permit is ismed.
My Worker's Cornpennuon Insurance carrier and Policy number are:
Cartier. policy No.:
CERTIFICATE OF EXEMP 1ON FROM WORKERS'
COMPENSATION INSURANCE
'mus section aced mtweemplemd if the permit uforerc hundred dn0ara($100)
nr ka)
I curry that in the performanen of the work for which Ni,permit W Wood.I shAH nm
employ any person in any mannerso as to become subject W to Workeri Compensadon
Law,of CJifomia.Data
Applicant
NOTICE TO APPLICANT:If.arm,making this Certificate of Exemption.you A.W
became mbject W the Wo,km's Compcnskdon pro risiom of ted Labor Code.you muss
.7z forthwith comply with mob pvvitoru or NW permit mail w dcemcd mwked.
ZCONSTRUCTION LENDING AGENCY
y
[-t Ihemb,01m that Nem isaconiwctnn kndingrpency,for Ne performametar
D:> the work far which flus permit W Wood(sec.3097,civ.C.)
0.Q Candor's Name
0. Z Lenders Address
U O 1 ratify that 1 Itaw read Nis application W sum Nu the oboes intonow.is
I,^ comem I,.m comply withall city and cowty ordinances and sum lass relating to
CSJ' building construction.and hereby auNorio repmsentatim of Nu city to envy upon the
W above-mcmiumcd property for inspection purposes
(Wil)agree to nw,indemnify and keep harmless the City of Cupenoto against
IimiliticAjudgmcnu.nous And experuce which may to an,way amen gi.1 said City
U of the traming of this permit.
APPLIICCANNTT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roc,fs
HAZARDOUS
Signature,er ApplicaDoe
HAZARDOUS MATERIAupa DISCLOSURE Type of Roof
Will Ne applicant or future wilding occupant.ChpyoreZ handle Heardons maeerial
u deMd by the Cupertino Municipal Cie.Compeer 9.17.and the HCJN and Sa(cty
Code.section 25732(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ON.
Win Ne appremt or comm wilding nenpant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
Wmtt harardma air cuouna nsnta a defined by Ne Bay Am Air QuJity Management all new materials for inspection. -
c1T
❑Yes ❑No
Ib�wmW Neh.Sccuma505. 5533 mcntaunderChaperd dr Wkhng
doesO N&SaferyhtnAt A ectiau et It myra,umbil.1 u, or,tN#ifNem�fft -
Jms test currently haw.mnsns tau it a my reaponthility m miry to aecupmt of Ne
rnquiremems worm mph be met prior mutmme of a CcrtiOpe of Occupant'. Signature of Applicant Date
OwA.rmmthcn.adngem Dam All roof coverings to be Class'W'or better
CITY OF' CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: pdtg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35904031 . 00
DATE ISSUED. . . . . . . : 12/01/2008
RECEIPT # . . . . . . . . . : BS000006722
REFERENCE ID # . . . : 08120012
SITE ADDRESS . . . . . : 2:L020 CORY CT
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : TATKAR, VIJAY
ADDRESS . . . . . . . . . . : 21020 CORT CT
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4219
RECEIVED FROM . . . . : JEFF JORDAN
CONTRACTOR . . . . . . . : JEFF JORDAN LIC # 29100
COMPANY . . . . . . . . . . : FAST WATER HEATER
ADDRESS . . . . . . . . . . : 12601 132 AVE NE
CITY/STATE/ZIP . . . : KIRKLAND, WA 98034
TELEPHONE . . . . . . . . : (800) 454-8955
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 449 . 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 AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 106 . 56 VISA
----------------
TOTAL RECEIPT 106 . 56
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ----------------------------- -------- ----------------------------
518 WATER HEATER
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
•r U nrR,T'N� Fex(408)777-3333
11., rrG IV Building Ike artment
JOB ADDRESS: 21020 CORY CT
PERMIT#�
OWNER'S NAME: TATKAR,vijAY PHONE# 408)368-2585
GENERAL CONTRACTOR:FAST WATER HEATER COMPAN FAX# 425.814-9516
I am not using any subcontractors: 1211/08
Signature Date
Please check applicable subcontractors and com lets the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE#
Cabinets&Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring:Carpeting
Linoleum/Wood
Glass/Glazing
• Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plwmbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
0
423844
Permit No:
(office use only)
City Of Cupertino Building Permit Application
• E-Mail: Building-Permits t1 cupertino.ora (Address is case sensitive).
Jobsite Address:21020 CORY CT Date: 12/1/08
Assessor's Parcel Number: 35,g010 !�.I , 00
Owners Name: TATKAR, VIJAY Phone No: (408)368-2585
Project Valuation: 449.00
Building Permit Info: Bldg Elect Plumb X Mach
Job Description
Remove/Replace Gas Water Heater
Contractor information
Company Name: FAST WATER HEATER COMPANY Phone No:
• Contact Name: Carol Randall Fax No: 800-454-8955
Address: 12601 132ND AVE NE E-mail:carolr@%stwaterheater.com
City, State & zip code: KIRKLAND, WA 98034
State Contractor's Lic. No: 877489 Expiration Date: 5/31/10
Worker's Comp No: 1761660 Expiration Date: 12/1108
Carrier: California State Fund
City of Cupertino Business License No: 29100
Credit Card Information
Credit Card No: _ Expiration Date: 11/10 0
Name on Card: Jeff Jordan
Visa ® MasterCard ❑ American Express ❑
The Building permit application and a completed & signed
• contractor/subcontractor form need to be submitted with each permit.