08120049 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTagtjNFORMATION` '..
BUILDING ADDRESS: PERMIT NO.
19965 BRENDA HOME DEP
OWNER'S NAME: PERMIT ISSUE DATE
4:2601 132NE) AVE NS
E A CONTROL N0.
(425) 636-7054
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLI)<i ELECr PLUMB MECH
uao LICENSED CONTRACTOR'S DECLARATION lob Description
Z1 hereby affirm that l am lio:mcd order pmru visieof Chi pser 9(commencing
n< with Section 7")ofDiHsion 3 of the Business and Pnefariom Code,and myliceteu
in full fm¢and effect. REMOVE/REPLACE GAS WATER HEATER
Dn— Lemom clary Lr.g
�k- Dow Comractor
ARCHITECTS DECLARATION
I mdnsu tel my Plate shall be need as public Momis
DT u
g seemeditf s final
5 OWNER-BUILDER DECLARATION
I hereby+from Nal 1 em exempt from the Contractor`s Isms,law for the
A O following mama(seed.71113.Business;and Profeariane Code:Any city or county
e: which requiem a permit to construct alcor,improv,demolish.m repair any soncmm
_Ztn prior to its iuuance.atm requous On applicant forsuch permit in rile a signed statement
Esq Nn he is licensed pursuantonmeProvisional ofthe ConuachtesU..Law(Chapter 9 Sq.Ft.Floor Area Valuation
yFg (eommnmingwith Section 7000)ofDdvhion3ofOnBusiness and Profession,CMe)or 449
that hees exempt Ocretrom and thm hands for use alleged exemption.Any violation of
Salon 7071.5 by aro'application for a Permit subjects this applicant in a civil penalty of APN Number Occupancy Type _
Tat come than Rw hundred della.(Ts00). 36943004 . 00
❑I0 0wook.f red propaty.ormy wpldym unted Orowagesa Bre"trmu eompewness
will domewods cod,The Ctmunot,License Law ffered for
apply 0 an.Business
and Required Inspections
antl property
wh obu Code:The Conmcmr`s red who law does Out apply lf an owner is 9 P
man enywbos.monied Oat suchres i prowmets me
oroelfar through his
own employees,provided Oat such impmsemenu are us corn f orailred forsale.,.
builder,On building m improvement ts salt within ane wan of completion,me owe of
sale.). will love the WNess of proving Nat ha tlitl ter build Or impraw(a purpose a(
saleJ.
0 1.as oda M lir pmpMy.am eaclu4wly contracting with licensed contsmtms m
caK4nCt me prafM sec.7044.BLLriae6 and POIesSTN Cade:)TAC ConB,em/s V-
conse Law does not appy to an owner of property who builds or improves themon,and.
who contracts for such projects with a comrumr(s)limited pursuant in me Contractor`s
License Law.
0 l am excre"under See .B@PC for this mamn
Owren Date
WORKER'S COMPENSATION DECLARATION
11 hereby am.order penalty of perjury oro of me fllOwdns declxnd.
1 ham and will memorie•CerdBara mfComena m xlf-inwt for Worker`s Compne-
tion,as ProvidW for by Secdan 3700 of the labor,Code.for the performance of me
work for which cods permit is issued.
0 I hose and will m ussum Wmitml Compensation Inmrano:,as required by Section
37f1 of the labor Code,for the performance of the work for which mit permit is mued.
My worker`s Compenuder Intrance canna and Policy number me:
Carrier. Policy Na:
CERTIFICATE OF EXEMPION FROM WORKERS
COMPENSATION INSURANCE
(Musectim and trot N completed Ifft permit is for one hundred dollen($100)
or less)
I astifv met ld lice performarce of the work for which this permit is issued,I"I out
employ any person in any Winner so as m become sobjea to the Wortras'Corepmuadon
Laws of Califomia Dam
Applicant
NOTICE TO APPLICANT:If.after making this Cenirocam of Eace ption,you should
become subject to the Wm en's Compemition previsions of the Labor Cods you mute
O forthwith comply with such provisions m cols permit shall be deemem
d ooed.
z(VICONSTRUCTION LENDING AGENCY
F+ Ihemby ofrorm than them u a constmninn lending agency for the purrormana of
f>» me work for wWO ids permit is ismrd(Ser.3097,Civ.C.)
4 0 Lenim' Name
D Z I nwme: adorer
U Q 1 omdfy that I hale read this application and sum that the above information is
lL comm I agmm w comply with all city and county onlina ens and sum laws relating In
.0 building construction,and hereby solicit mprurnambMs of mu city In enter upon the
4
ab ve-mentimmd property for inspection purposes
I%)agree to saw,indemnify and oecp harmless the City of Cupmim against
iliabilides.judgments.cmu and espouses which may in any way area+guns,saidCity
U Z in eanme some of the gandng of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. -
Re-roofs
Signature of A,dicanVConmacmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building oaupantsmt or handle harvdow material
as defined by the Cupertino Municipal Code.Chapter 9.11 and On Health and Safety
Code.section 25532(.)7
❑Y. ON. All roofs shall be inspected prior to any roofing material being installed.
Will dm applicant or future building ouopant use equipment or dcviw which If a roof is installed without first obtaining an inspection,I agree to remove
I hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
auict7
GYq ON.
I hoe real the haardotss mannish requirements under Clbpta6.95 of me Califm-
nuHind"Salloty Code.Sadao x5505.15533 and 25534.1 undctwnd mu if On building
does Ira currently bow a mnana thus it is my msponsibilky an neofy no oaupant of On
requirements which must he can.prime In ii3mec Of Ccr;Rcam of aCupmcy. Signature of Applicant Date
Owner or authommi agent Dam'
All roof coverings to be Class'A"or better
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36943004 . 00
DATE ISSUED. . . . . . . : 12/04/2008
RECEIPT # . . . . . . . . . : BS000006752
REFERENCE ID # . . . : 08120049
SITE ADDRESS . . . . . : 19965 BRENDA CT
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : BENJAMIN LIN
ADDRESS . . . . . . . . . . : 19965 BRENDA CT
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
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
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
i .10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
OF Fax(408)777-3333
OCUPERTINO -�
Building Department
JOB ADDRESS: 19965 BRENDA COURT PERMTT#
OWNER'S NAIy16: LIN,BENJAMIN PHONE# (4080)9966-2271
GENERAL CONTRACTOR:HOME DEPOT y� FAX# 425-814-9516
�a`'`PN�Lt' k�QP I am not using any subcontractors: 11/4/08_ _
Signature Date
Please check applicable subcontractors and com Tete the followin 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
Owner/Contractor Signature Date
• -• Permit No: C$12-00449 000000
(office use only)
• City Of Cupertino Building Permit Application
E-Mail: Building-Permits(o)cupertino.org (Address is case sensitive).
Jobsite Address:19965 BRENDA COURT Date: 11/4/08
Assessor's Parcel Number: 3(vq `4-'5 Obq Ov
Owners Name: LIN,BENJAMIN Phone No: (408)996-2271
Project Valuation: 449.00
Building Permit Info: Bldg Elect Plumb x Mach
Job Description
Remove/Replace Gas Water Heater
Contractor Information
Company Name: HOME DEPOT Phone No:
• Contact Name: Carol Randall Fax No: 800-454-8955
Address: 12601 132ND AVE NE E-mail: carolr@fastwaterheater.com
City, State & zip code: KIRKLAND, WA 98034
State Contractor's Lic. No: 602331 Expiration Date: 9/30/10
Worker's Comp No: 1928756 Expiration Date: 3/1/09
Carrier: AMERICAN HOME ASSURA
City of Cupertino Business License No: 6pplte4
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
contractor/subcontractor form need to be submitted with each permit.