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08120054
CITY OF CUPERTINOr«c BUILDING DIV ION PERMIT CONTRACTOR IN.FORMA.T O1V BUILDING ADDRESS: PERMIT NO. 1 OWNER'S NAME: PERMIT ISSUE DATE A 8 8 CONTROL NO. 425 636-7054 ARCHITECDENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH O p LICENSED CONTRACTOR'S DECLARATION - 1 boat affirm that 1 am licensed under provision of Chapter 9(commencing Job Description Mitt Scudo.7M)ofDiniA.O3 of dm Business and Professions Code,end ery license Is "oH in full to=and cfom REMOVE/REPLACE GAS WATER HEATER j M z Licenso Class Lk.g nFp No Contractor 7W ARCHITECTS DECLARATION U 1 ondersund my plans shall be used u public records g t; Iicemed Professional OWNER-BUILDER DECLARATION ii Y 1 hc¢by eMr.that 1 am exempt from the Contractors Licence law for the - OO following mason.(section 703 LS,Business and Profetiom Code:Any city or county j2 V which to,mal a permit to rnnsneL cher,improve,demnli h,or repair any structure �Z} at print in its struarms. m legnlms cite appllcmt farsuch permit to ELL'm Ek a signed staern < shubeifliccmedpusaanttomeprovisions ofsheContracoohUccnmLaw(Qupter9 Sq. Ft. Floor Area Valuation s€$ (commencing with Section 7000)of Division 3 of the Business and Profession Code)or r3— that he is exempt limefmm and the bar's for the alleged exemption.Any violation of 5449 Scmlon 7031.5 by am applicant fora permit mbiecu the appimmtto a civil penalty of APN Number Occupancy e not mom d300). p y 'than live hundred dollar(5 �T+7 p 01.0 owner of lbe property.err M employees with wages u Amu sole eampenadon, 37523042 . 00 wiD do the work and the suverum u not incurred m.Bawd for sale(Ser.7014,Butimsr and P.1.1mm Code:This Cormcmfa License Law does an,apply to an owner of Required Inspections property who Wildsorimproves thereon,and whodoessuch work himselforthmugh his Own employ=.provided that such improvemenu art not Intended oroRere l forsale.If. however.Ne building or imp evemant is mid within on year of completion.the awrcr- Wilder MB have she bonder of proving that he did Out Wild or improve fm impose of sale.). . Q 1,as owner of the property.am exclusively convecting with licensed contractors to consumer the projett(Sec.7014.Business and Profession Cade:)The Coavanots U. come law d=out apply m an owner of property who Wilda at improver demon.W who coroners for such poieN with a comracoor(s)Rcemed Pursuant to the Contractors Lice"¢Taw. U l am saempt under see ,B A P C for thu moron Owner Dau WORKERS COMPENSATION DECLARATION I hereby a0-um under penalty of perjury,om of the following declensions I haw;and will maintain a Certificate ofComenuo self-intim for WorkersCrumpet. salon,u provided for by Section 3700 of the Labor Codem,for,the performance of the werk for which Nu permit is issued ❑I have and will maintain Workers Compensation Iruursnec,u acquired by Sectian 37110 of she LaWr Code,for the is dmmeue of she warm for which this permit is issued. My Workers Compenamon lawns ce carrier and Policy number art: Cartier. Policy No.: CERTIFICATE OF EKEMP ION FROM WORKERS COMPENSATION INSURANCE Crtismedan need notbe completed If the Permit Is forts hundred dollars(SIM) or leu) I certify that in the perform.a the work for which this permit is issued.I"I ma - employanypersoninmymanrermutobecomesublecttodmWmlc Compensation Laws of Callmmia Dae Applicant NOTICE TO APPLICANT:IL after makiog this Certificate of Eacmption,you should become subject in Use Workers Com acmadon innovations of de labor Code.you must .,z foMwidn comply wish such provisions or this permit shall be domed revekcd. z 0 CONSTRUCTION LENDING AGENCY [-�4 I hmeby of ares that then is a construction lending agency for the performance of Ili > de.,it for which she Permit is raved(Sec.3097.Civ.C.) A Lenders Nuns z Lenders Address U O I certify that 1 have read this applieasion arb Auto that the above information is I5.^. cortex 1 agme to comply with LI city and county ocilnanrs and sum laws relating to .O CS'J' Wilding cortsmsion,and hereby mNonin representatives of Nu city to cmaupon Nc W above-mentimr l pmpeny for impeerian puspmes 0. (We)agree to ave,indemnity and keep hartnleas she City of Cupertino against fq IiabilidgjudgmcnLL,crsLL end expense which may in any way accrue agtinstssidCity U az in consequence of the Starling of this permit. t-+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. . Re-roofs Signature of ApplicmVComsxtor Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or Futuro bolding orcupantatom or lurdk harardous manorial u dcli ed by the Cupcnim Municipal Code.Chapmr 9.13.and the Health and Safety Cale,Schon 35332(x)7 ❑Yes ON. All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection,I agree to remove Will de applicant or future define S by do Ba ecu equipment or den=Mich g t haraNnus At ronuminanu u defined by Ne Bay Ana Air Quality Managcmem all new materials for inspection. u nnT ❑Yea ON. I hem rest the buardcus materials req.immcnu tmdcr;&pter6.95.fNe Califon- . ria lkalth&SaferyCada Sectiou 25505.25533 avd23534.1 urormvld Natifthc bolding does Out currently have a mnam,ded it u my responsibility On notify the o copmt of de myuimmcns which most W met prior m issuance of a Ocnlfeate of Occupancy. Signature of Applicant Date Owner or mohodm0 agem 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 . . . . . . . . : 37523042 . 00 DATE ISSUED. . . . . . . : 12/04/2008 RECEIPT #. . . . . . . . . : BS000006754 REFERENCE ID # . . . : 08120054 SITE ADDRESS . . . . . : 10454 STERLING BLVD SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : LINDA BORRMANN ADDRESS . . . . . . . . . . : 10454 STERLING BLVD 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 .46 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 a Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 9CUPEkTINO Building De went JOB ADDRESS: 10454 STERLING BLVD PERMIT# OWNER'SNAIyM: BORRMANN,LINDA PHONE# (650)941-1087 GENERAL CONTRACTOR HOME DEPOT �7 FAX# 425-814-9516 I am not using any subcontractors:_ C.sa, a�/P 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 Pencing 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 000000 Permit Noe �$I2�5�{ (office use only) City Of Cupertino_Building Permit Application • E-Mail: Building-Permits(cDcupertino.org (Address is case sensitive). Jobsite Address: 10454 STERLING BLVD Date: 11/4/08 Assessor's Parcel Number: 375- 23 ()q2_ Owners Name: BORRMANN,LINDA Phone No: (650)941-1087 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: eContact 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 Llc. No: 602331 Expiration Date: 9/30//o Worker's Comp No: 1928756 Expiration Date: 3/1/09 Carrier: AMERICAN HOME ASSURA City of Cupertino Business License No: PIrppk,ed 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 contractorlsubcontractor form need to be submitted with each permit.