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08120055 CITY OF CUPERTINO - BUILDING V VISION PERMIT C N`CItACTOR INk`UTtM TI ,N,� BUILDINGADORESs: PERMIT NO. 20697 _UNBAR D HOME DEP OWNER'S NAME: PERMrr ISSUE DATE ')NE A CONTROL NO. (425) 636-7054 ARCNITEcf/ rINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH up2 LICENSED CONRtACTOR'S DECLARATION Job Description Z C 1 EcnbY arm Nu 1 am I'xcNed uMv Pro"ivoN o(CMpv+9(commencing P <t� Tins See thn 70M)of Divisor 3 ofdu Become:and Profession,Code,and my license la n_cm in full fame andelfern. REPLACE GAS WATER HEATER M z License class c—qq Dau Contractor. ��W ARCNr1ERS DECLARATION 77 1 undcnund my plans shall be used as public r cords DSyu aLLbS. Led PookesmI NN OWNER-BUILDER DECLARATION f 1 hereby afire that 1 em exempt from the Contractor's License Law for the C pe D following moon.(Section 7011.5,Busineu and Professions Codc:Any city or county S_ which m,,me,a Permit to connotes,alar,improve,demolish,or repair any oNmum prior In is moomeC,also requires the applicant foreach pmoritto file asl(nedsaenom, < Nuheislicensed pursuant tothe provisions ofthe Contractor's LucessLaw(Chapter 9 Sq.Ft. Floor Area Valuation YFG (commencing with Sermon 700M of Division 3 of the Business and Profesions Cod.)Or 3 Nat o is exempt therefrom and de basis for the alleged aemption Any violation of 0 Section 7031.5 by airy applicant for a Permit eabjecu the applicant W a civil penalty of APN Number Occupancy Type nor mem than film hundred damn(15do). 32633038 . 00 ❑I.uoweer of the Propmty,amy emPlayw wins wagsudc'v Sou tmmpewdon, will dohowedr,and dampeturehnminmededoranemdforule(See.T(u<.Becomes Required Inspections and Rct so nor M Cade:7ContrYmes License Lao does apply a sm W Nr of 9 P pmpWyvho Wildsarimpaven Nermn,and whodwauc s workhimself or through his awn employers,provided that such imp cremeres an,not intended PoQemd Lenoir U. however the Wilding or improvement is Sold within one you of completion,the owner- Wilder win have the Wren Of proving dol he did ret build ter improve for puryax of ale.). 1,as owner of the propenY•aro exclusively contrusing with licensed countesses W construct the Prolan(See.7054.Business and pnomm.ns Code:)The Contractors I.I. conte Law dons sol apply W an own¢of property who builds or improvn desmon,and. who¢.tuts(o such Paul"wins aconmma(s)licensed purses.,W de Contrxmr's License Law. ❑Lem exempt under Set ,B&P C for this mason . Owner Dao WORKER'S COMPENSATION DECLARATION 1 hereby afire under penalty of perjory are of the following decluumad I hsve and will e x r,xim•Conti ade of Consent W Self-insure forWmk es Compen- tion,as provided for by Section 3700 of the laor Code.for Ne performance of use want for which Nis permit is lamed. I have and will maintain Worker's Compensation I...as required by Saver 3700 of dm Labor Code.for dW performance of the wont for which this Permit is issued My Worker's Compensation Wunmma anis and Policy number am: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thu xecdon recd rot he completed Bthe permit It form hundred donan(5100) or lose) 1 Cm ify Wer he the pmrseemec,of Ne work for which this permit is issued 1 shell not employ any peon.in any mamcr se as W become subject W the Worker'Composed¢ Laws Of California.Date Applicant NOTICE TO APPLICANT:If,ager making this CcniBau of Exemption,you should become Subject W the Worker's Compensation provisions of the labor cht you tau vJ O forthwith comply with such provisions or Nu deal ull W dared molted. 'Z,~N. CONSTRUCTION LENDING AGENCY l-r I hereby alarm dm then is.rnnomcdon lending agency for the petforman¢uf CL> the work for which this permit Is issued(Sec.3097.Civ.C.) GUndoes Name D z Lender'!AM. U Q 1 exact that 1 have rad this application ao sum dem the.ore information i5 0, f" Correct.1 agme W comply with all city and County aNiname5 and Sum laws ochtimg to .DU building conswction,and ombg audience representatives of this city W enter upon rhe r U move-recndoxd property for inspesi.n purport (•+t1 (WC)agree In Pte,indemnify and keep harMen de City of Cupertino against fn liabilities.Judgments.costs and expenses which may In any way acme against Pio City U z in consequence of the staining of this permit. ti APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. Re-roofs Sipancrool'ApplicenuCommucher Dem HAZARDOUS MATERIALS DISCLOSURE Type of Roof . WIII We icent nr Iuni Wilding acupant mom or handle Health material u dentthe Cupertino by upenMunicipal umdcipal Code.Chapter 9.13,and do Hexith and Safety Code.Section 255324P All roofs shall be inspected prior to any roofing material being installed. ❑Ya ON. Will the applicant or(.tort Wilding ocaput.nc comment or devices whim If a roof is installed without first obtaining an inspection,I agree to remove it huaNnus air coraminanu as defined by the Bay Area Air Quality Management all new materials for inspection. .CIT cYa 0N I have mrd the hasendsus reateruu no t immenu tx der�itapar 6.95 ofdte Califor. ria Health&Safety Calc.Secdond 25505.25533 aro 25514.1 understand that ifthe Wilding does not currently have a anon,out it u my responsibility W notify the oce.pant of the requironanst which m.eee=Iprior as issuance oracmdfmam.faCCPa.. Signature of Applicant Date Owner ormtsoneed.gcm Dam All roof coverings to be Class'n+ 'or better I CITY OF CUPERTINO 4 ITEMS OF 28 PERMIT RECEIPT OPERATOR: suew COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32633038 . 00 DATE ISSUED. . . . . . . : 12/04/2008 RECEIPT #. . . . . . . . . : BS000006760 REFERENCE ID # . . . : 08120055 SITE ADDRESS . . . . . : 20697 DUNBAR DR SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO* IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : DALE T. HELGERSON ADDRESS . . . . . . . . . . : 20697 DUNBAR DR 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 0 . 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 ID DESCRIPTION VOICE ID DESCRIPTION ----- ---------------------------- -------- ------------ 518 WATER HEATER • /q�5— 000000 Permit No: U (office use only) City Of Cupertino Building Permit Application • E-Mail: Building-Permits(a)cupertino.org (Address is case sensitive). Jobsite Address:20697 DUNBAR DRIVE Date: 11/4/08 Assessor's Parcel Number: 3_2� mo3 Owners Name: HELGERSON,DALE Phone No: (408)836-8324 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/lo Worker's Comp No: 1928756 Expiration Date: 3/1/09 Carrier: AMERICAN HOME ASSURA City of Cupertino Business License No: .ftppl,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. Community Development 10300 Torre Avenue •� Telephone Cupertino8) 77793228 CI OF Fax(408)777-3333 •CUPEkTINO Building Department JOB ADDRESS: 20697 DUNBAR DRIVE PHRMIT# 50-5-5--05M 50- _S OWNER'S NAME: HELGERSON,DALE PHONE# (408)836-8324 GENERAL CONTRACTOR:HOME DEPOT I� FAX# 425-814-9516 I am not using any subcontractors:— (� Gc "�aQP 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 hisulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile • Owner/Contractor Signature Date