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08120042
CITY OF CUPERTINO PERMIT s� �tax� a\BUILDING DIV151CN O �I�rFO"?RM.' A"T` IV'=N BUILDING ADDRESS: PERMITNO. 10450 N PORTAL AVE HOME DEPOT 08120042 OWNER'S NAME: PERMIT L'Sl1E DATE PRTRRA K19TN 32601 12;�Nl) AVE NE; 12 NE: RA M CONTROL NO. ARCHfIEC(ENGINEER: BUILDING PERMIT INFO RMV/RPLC GAS WTR HTR BLDG el.Ecr PLUMB MEcx 0 0 0 0 �oj LICENSED CONTRACTOR'S DECLARATION IOb Description 1 beeby affirm Wt 1 am li¢aad under provisions of Chapter 9(comm1encing P with Section 7").f Division 3 of the Busi.and!Pmfcasiosm Code,aom my license is in full to.and effect j q Z Linemen Clan Lic.g ' ^ppp DateCoorwwr ` ARCHITECTS DECLARATION C 1 comem ed my plus shall Ec coed as public mcoNa 6 �G Licensed professional OWNER-BUILDER DECLARATION '�<F I hereby (Siem Nat 11. exempt from the Cssiums o :Any c law for the i 00 following reason.(Section]031.5,...Mucus and w,der.ns Cale:My city m county _ which requires a aenil m coMwouc4 alter.impmw,demnlLN,or rtpoir any.trucmrt prier an its issuance.at..requima thoappikam f.,mch pe.it o file.signed statement s< that x is licensed pursuant to the provisions of do Canmacsel licome law(Chaptm9 Sq.Ft.Floor Area Valuation yF� Mommexing with ScWum7000)of Division 3 of the Busman and Prulzom Cmdc)or y that he u mu mpt theaeh.m and the basis for the alleged exemption My violation of Seen.7031.5 by mr,appllmm for a permit mbjecu the applicant to a civil penalty of APN Number Occupancy e outmort Nu five hundred dollars(SM P Y •]Ty P ❑1,a owner of the property,or my wployen w'mh wags u th"v auk eompensstiun, will do thcwmk,and the he Contemn. e me,kimens or ane do forum(SIL.To m.B mer of and property W Calc The G.nwmem.License law dorm , apply m m owns of Required Inspections propertywhobaslids provided impmw therconandwho donsowhwokhimselfedtrorsahhu Ownemployers, ngri pr such inttmid whine not intended OroOerrm for sale,u however,de buildingurimprovement4our within oro Wild of covPletiw.thepomonamer. of builder will have de burden of povind duo he did rot build or improve for puryom a( sale.). ❑1.as mares of she property.am esclusively...causing with licensed contractors b construct the project(see.7044,Business am Pmf=.w Calc)Tie C.mcacme.U. cense Law dors rot apply in an owner of property who builds or improvs thereon,and who contracts for such projects with a comeactoo(s)licensed puncture in the Connector's License Law. ❑l am amp,under Set .B d P C for this mccn Owner Dau WORKER'S COMPENSATION DECLARATION 1 hereby.1E.under puna ty of perjury. f the following decldad.nc hart and will maintain a Cmifiente.f Comeau m self-insure fm WorkC.C.mpen- 'on,as posided for by Sectiun 3'100 Of the Labor Code.for the perfmamen of the wart for which this permit is moved. ❑1 haw and will maintain Worker's Compensation Insurance,as required by Section 3700 of Ne Lobo Code.for me performance mrthe work for whim Nis permit Is issma . MyWorker's Compensation hsamtce carrier"Policy number me: - Cartier, Policy No.: CERTIFICATE OF FXEMPT70N FROM WORKERS' COMPENSATION INSURANCE (Thu xeehon need not be completed if the permit la forma,hun to ddollan($10(i) or ins) I cenifv that ta the pale mame,of the wart for which this permit is burned,I shall not =ploy acypmen In my manmfm as in b.Wme subject in the Wmkers'Coo ensmien Lawn of Califomia.Dam Applimint NOTICE TO APPLICANT:IL after making this Certifiwm of Exemption.you should become subjeet m the Worker Cmnpensation previsions of the labor Code,you most .J z forthwith comply with mch prmvisio;or this pormit"I h,decrmd mvokcd. . Z y CONYMUC71ON LENDING AGENCY [—� I berthy affirm thatYxm is a comwctinn lending agency for the perfunnmce or 15 > the wok for whim then permit is issued(Sec.3097,Civ,C.) 4 p lander.Name iti. z lender's Address U O 1 cordify that 1 haw need this application and state this the above mimmation is Is, coo�l agree m comply with all city arm county orditumes and state laws reusing an .O building cmnsummmn.and hereby authorise rtprmmduveu of thucity to cmeropnn the W shm ow- entionod property for htspemme iun purpt (We)agree to saw,indemnify and keep harmless the City Of Cupertino against ti(� Liabilities,judgments.casts and expenses which may in my way mcme against said City U z in consequence of the gaming of this permit. �". APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. Re-roofs Signature AppliwHAZARDO Dam HAZARDOUS Wilding MATERIALS LmumDISCLo$URE Type of Roof Willy the C icmt o for. C de.Chm c,9re m Assert huuth ms and Safe,, . C ic,Sec by the Cupertino Municipal Code.Chapmr 9.11.and due Health and Safety Code,section 15532(x)? Oyes 0N All roofs shall be inspected prior to any roofing material being installed. Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove I Weamnw air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection. U ul? ❑Yap ON. I have mad the loam.usmatedalsmquimmcnu under upmrb.95 ofthe Califor. nia Health&SakLyCode,Sections 755115,15533 and 25334.1 undcrsund twif the building does not cuncntly haw•tenant,that it is my rup.wibility m notify the.ceupmt or the requirements which most W met piorm issuance of a Certifeae Of Occupancy. Signature of Applicant Date Owner or mthom.d agco Dam' All roof coverings to be Class'%W'or better CITY OF CUPERTINO • 4 ITEMS OF 24 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 31629014 . 00 DATE ISSUED. . . . . . . : 12/04/2008 RECEIPT #. . . . . . . . . : BS000006763 REFERENCE ID # . . . : 08120042 SITE ADDRESS . . . . . : 10450 N PORTAL AVE SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . : OWNER . . . . . . . . . . . . : PETERA KLEIN ADDRESS . . . . . . . . . . : 10450 N PORTAL AVE CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2325 RECEIVED FROM . . . . : JEFF JORDAN CONTRACTOR . . . . . . . : FRANK BLAKE LIC # 30610 COMPANY . . . . . . . . . . : HOME DEPOT ADDRESS . . . . . . . . . . : 12601 132ND AVE NE CITY/STATE/ZIP . . . : KIRKLAND, WA 98034 TELEPHONE . . . . . . . . : (425) 636-7054 • 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 VOICE IO DESCRIPTION VOICE ID DESCRIPTION ----- -------- ------------ 518 WATER HEATER • rte. Community Development Torre Avenue M Cupertino CA 5014 Telephone(408)777-3228 OF Fax(408)777-3333 OCUPEkTINO Building Department JOB ADDRESS: 10450 N PORTAL AVE PERMIT# O(:/,? D v L/� OWNER'S NAME: KLEIN,PETERA PHONE # (408))725-2544 GENERAL CONTRACTOR HOME DEPOT FAX# 425-814-9516 I am not using any subcontractors:_ Cc'a �lz ,>lxQP 1114/08 Signature Date Please check a licable subcontractors and complete the foIlowmi 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 Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile 0 Owner/Contractor Signature Date �O /� 000000 ' Permit No: Op� Q (office use only) City Of Cupertino_Building Permit Application • E-Mail: Building-Permits aOcupertino.org (Address is case sensitive). Jobsite Address:10450 N PORTAL AVE Date: 11/4/08 Assessor's Parcel Number: .31(0� go07 `f' °o Owners Name: KLEIN,PETERA Phone No: (408)725-2544 Project Valuation: 449.00 Building Permit Info: Bldg Elect Plumb x Mech Job Description Remove/Replace Gas Water Heater Contractor Information Company Name: HOME DEPOT Phone No: tContact Name: Carol Randall Fax No: 800-454-8955 Address: 12601132ND AVE NE E-mail: carolr@fastwaterheater.com City, State & zip code: KIRKLAND, WA 98034 State Contractor's Lic. No: 602331 Expiration Date: 9/30//0 Worker's Comp No: 1928756 Expiration Date: 3/1/09 Carrier: AMERICAN HOME ASSURA I City of Cupertino Business License No: ✓ opt��l 3 b `O Credit Card Information Credit Card No: Expiration Date: 11/10 Name on Card: Jeff Jordan Visa © MasterCard ❑ American Express ❑ • �The Building permit application and a completed & signed ontractorisubcontractor form need to be submitted with each permit.