08120052 CITY OF CUPERTINO
BUILDING DIVISION PERMIT < CQ�ITRAC'COR IlYI4'URMAT�O.
BUILDING ADDRESS: PERMIT NO.
7573 BOLLINGER RD HOME DEPOT 08120052
OWNER'S NAME: PERMIT ISSUE DAIS
NE: SA CONTROL NO.
12998
ARCHRER/FNGINEER: BUILDING PERMIT INFO
RMV/RPLC GAS WATER HTR BLDG EIEC? plume MEcx
0 0 0 0
u O p LICENSED CONTRACTOR'S DECLARATION -
uC 1 hereby affirm Nal 1 Sm li¢ucd mt9
under Psiov of Chapter 9(ammmaing Job Description
�W wire Section 70f111)of Division 3 of the Business;rid Professions Code,need my Become is
in full forte sod effect.
IBcaow Class Lk.IF ,
Dale Camraoar
e ARCHRE(.'rS DECLARATION
;�U IunMasunJ mY Plans shalloutrdu W6lle recoNs
a
9,1 Licensed Professional
e OWNER-cant r,fr, DECLARATION
1 Wreby M.on 1 em esempt stem the Contractor's Liana taw for Ue
no which re vires a.(Section 7 o 13,Business;and PrOn, asiou Cade:Any city per aunty
s which requites a permit to cnmwcL alter,hnpme,dcmnlW.or repair any ttroetme
If Imarmi4 iensed rament,In,San,
movisio an,son for each Permit LiecassiLa (chapsstatermS
x
< (comboencing itpursuant w the of Division
of de Canuinessand PeSlAw(Chapar9 Sq.Ft. Floor Area Valuation
Y 5 (commencing is exempt
S normaon and
da, ivuion 3 of the al Business and on.Anyaiu Code)of
y�$ tMt o Is cxernpt mert(rom and tbo bassi for the alleged esempUan Any violauan of
Seaton 7031.5 by any applielot far A petmft subjau the applicant to a civil penalty of APN Number Occupancy Type
tet mole dun fiw hundred dollars(SSW).
1,u owoer of the pmperry,a my wployaa with wage u thek sole mmN=don,
wiU da tbo work.and Ue sanctum u nut mantled per offered forule(Scc.70N,Business
and penfessiou Cade:Tha Conaaclorn teto
s Liccom Law dean apply an mmr of Required Inspections
property who Wilds orimprom mereon,and whodoessah workhimulf orthrough his
own employees,provided that rcb improamate arenot intended uroReed ferule.ff.
however.Ne building or improvement A sold within ons Year of completim,the owner-
builder will lave the burden of proving that he did tet build or Impure far purpose of '
Sale.).
❑1,u owner of the property,am exclusively,musctinl with lianded coronae:IS
construct the pmjea(Sec.7044.Bossiness and Profession Cade:)The Contractor's Li.
came Law does not apply IS an owner of property who Wilda or improves thereon,and.
who contracts far Such prejams with a crunnu A)licensed puouut to ft Contactors
License taw.
❑I Sm esempr under See .B&PC for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury as of the following declamdev:
I haw and will rote uin a Certifncamof Covent he self-iuue far Worker.Compen-
tion,as,provided fel by Section 3700 of the Labor Cade.for the performance of the
work for which this permit is muted.
❑1 have and will maintain Workers Compeesstion Insurance,as required by Section
3700 of Ne labor Code,far the peffaran.of the work far which that permit is issued
My Workers Compensation htsunna caries and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('this section need tet be completed Ifthe permit is forme hundred dallus(111M)
or lass.)
1 artily dart in the perrtmmmee of Ue work far which Shia Permit it bound.l Shall ON
employ any penin in any matter so as w become subject to Ue Waders'Compcctution
Laws of California.Data
Appliom
NOTICE TO APPLICANT:If,afar making this Certificate of EaempOon,you soZ
becane Subject as to Workers CompenaUon provimov of the labor,Code,you masa
.J O foMwlth w.Ply with each provisions or Nu permit Nall be deemed revoked.
z .~N. CONSTRUCTION LENDING AGENCY
[-v I hereby offsite that there is a construction lending agency for the performance of
FC .fir to work for parent which Unit pet a Issued(Sec.3097,Civ.C)
14 0 Landers Nene
0.z0. lenders Address
U 0 1 certify that 1 ban mad this application and SAM that Ue above information Is
Ig,P const.I agree to comply with all city and county ordinarcv and a=lawn relating to
.�U Wildingconsutancra,and mrabyamhorine rtpeaOmtative,of this city to Omar upon me
move-mentioned property far inspection purposes
Hy (We)agree to sive.indemnify and keep harmless the City of Cupertino against
tu
liabilities,judgnn .casts and capcvn an
which may In y way acmeinst agaSaid City
U Z mmC Of the grandng Of this Ponall.
APPLI'ICCANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Sigeatue of AppliaHAZARDOU Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof -
Willtheapplicant noForum Wildinge.Chaptroe per handle Health anmaterial
u nn.Sec by Ue Cupertino Muniripal Code.Chapter 9.13.and the Health and Safety
coda,section us32(a)7
�Yn ❑Na All roofs shall be inspected prior to any roofing material being installed.
Will the applicant ar future building anmpant Saw cquipmenl m devices which If a roof is installed without first obtaining an inspection,I agree to remove
't hemdous air contaminants u defend by me Bay Area Air Quality Management all new materials for inspection.
ndct7
❑Yes C]No
I have mal the huardms materials requiemcm umkr Chapter 6.93 ofine Califor.
nine Hcolth&Salcty Code,Santav2f]II5,25533 ant 25534.1 uMerund mu ifSo Wilding
dao not curmntly haw a tont,ter it ie my mapovmility to tmdfy tie occupant of Inc
mquimmcnu which muco met prior to Issuance ofa Certificate of Occupwq. Signature Of Applicant Date
Owner or authorised agent Dow All roof coverings to be Class'RS'or better
CITY OF CUPERTINO
• 4 ITEMS OF 24 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . . 35922041 . 00
DATE ISSUED. . . . . . . : 12/04/2008
RECEIPT # . . . . . . . . . : BS000006763
REFERENCE ID # . . . : 08120052
SITE ADDRESS . . . . . : 7573 BOLLINGER RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CHEN CHIOU-FENG AND HSU TERESA
ADDRESS . . . . . . . . . . : 7573 BOLLINGER RD
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4334
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 639 . 36 VISA
---------------
TOTAL RECEIPT 639 . 36
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER
Community Development
10300 Torre Avenue
:r, I Cupertino CA 95014
Telephone(408)777-3228
CI of Fax(408)777-3333
OCUPEkTINO
Building De artment '
JOB ADDRESS: 7573 BOLLINGER ROAD PERMIT 11
OWNER'S NAlyfE: CHEN,CHIOU PHONE # (406)253-9957
GENERAL CONTRACTOR:HOME DEPOT FAX# 425-814-9516
I am not using any subcontractors:_ �'`"' "�`Y¢� 11/4/08
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Ladling
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
/ oaa000
Permit No: akll�C905"—
(office use only)
City Of Cupertino,.Building Permit Application
E-Mail: Building-Permits(cDcupertino.orq (Address is case sensitive).
Jobslte Address:7573 BOLLINGER ROAD Date: 1114/08
Assessors Parcel Number: -�S9aaoV(. d V
Owners Name: CHEN,CHIOU Phone No: (408)253-9957
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:
• 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: 3/1/611
Carrier. AMERICAN HOME ASSURA
City of Cupertino Business License No: Ahmk2c� v� I
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.