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08120057
CITY OF CUPERTINO BUILDING DIVISION PERMIT CONTRACTOR IIVFURMA.TION `,. BUILDING ADDRESS: PERMIT NO. 10695 MERRIMAN RD HOME DEPOT 08120057 OWNER'S NAME: PERbffI ISSUEDATE ONE: A O. CONTROL NO. (425) 636-7054 ARCHITEC(ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH l� �O ' LICENSED CONTRACTOR'S DECLARATION lob Description i�u 1 hamby affirm Jut 1 am licensed under pmvi siou of chapter 9(commencing with Sedan 700M of Division 5 of the Business said Prafamins Cade.and my licmue at 7 y in fail peace and efrccL REMOVE/REPLACE GAS WATER HEATER >4 z Lice.¢Clue Lie 0 n F' Da¢ Contactor ARCHITECTS DECLARATION 1 understand my Plain shall be need a public meoNs DV c O� Liec�d Pmfcuioedl 5 OWNER-BUILDER DECLARATION 1 hereby aRrm dam I am exempt from the CamramoA Lear.law far the E O O following reason.(Section 713 L5,Business and Professions Code:Any city at county S= which m,chas a permit an e..4 alas.impmw,demolish,or repair say sam lure _Z< prier W is iunsuma.&W,rcquirea Lha applicant for such permit N rile a signed summon pss Nat heuliaedcdpursuanttoNcprovisiouofda,Contractor'sLiame, awchapte,9 Sq.Ft. Floor Area Valuation Y F G (commencing with Section 7=1 of Division 3 of the Business and Proosaons Code)or $449 y Nat in u exempt therefrom and dr basis for Ne alleged exemption.Any violation Of section 7031.5 by any applicant far a permit subjects the applicant to a Civil penalty of AFN Number Occupancy Type net come Nan fin hundred dalws(s50m. 34216128 . 00 1,u owe of thm pepmy,a my employee with wage u their sok compensadon, and da Lhawoksand she heCoeeatetNundcdcaraw deal WEa(sec.Tu la.manner .nal Pcoreuioed Cade:The Conuacors Liemse law tion nal apply a sa owtrs of Required Inspections property who builds a im proves thereon,and who does such wart himself or through his own employer;provided that such improvements are tot intended maffared for ole.if. however.the building Cir hnFmvemcot is cold within as year of completion,fe owner- builder wi0 rare N,bum.of proving Nat he did Out build or improve Ter purpose of sal,.). ❑I,u owrcs M the property and utlusively contacting with Batted smntaetaa a coedtroct the project(Sec 7044,Busimis add Pmfessimu Code:)The Contractors U. roue law alma not apply to m owner of property who Wilds or improves shemon,sad, who contacts for such project with aconuazmr(s)licensed pursuant to Ne Commoner's Limens,law. lamuwptumes Sm. ,Ba PCferttmawn Owner Data WORKER'S COMPENSATION DECLARATION I hereby wed under Penalty or perjury orc of the following dataruiam - I haw and will ram um a Certificate account in uhf-insure far Worker'sCompen- on.as provided(o by Secuum 3700 of the labor Code.for Ne perfom an¢of the wok far which tht permit u issued. 1 have and will msimam Workers Compensation I...u required by scNan 3700 of Ne Lubar Code,far the pmferrosaecof the wart far which his permit is Wood. My Workeh Compeedathon Insurance ad.W Pali,number are: carrier. Poli,No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thais section recd Out be completed B Ne permit is fee =hundred do0saa($100) or las) 1 comfy the,in the performama of the work for which Nis Permit is issued.T shall am employ any parson in say maorr co as b become object N die Worked'Compeedatian Laws of California.Data Appliam NOTICE TO APPLICANT:if,after making this Certificate of Exemption,you should become subject to the Workers Compensation pmvWom of Na labra Cade,you masa .J O forthwith comply wish such provisions o this permit shall be decreed cooked. N CONSTRUCTION LENDING AGENCY (-. 1 mohy aRrm shsa fere t a corutuctinn lending aparty far the perfotmsaco of C4ft work for which disks Permit at issued(Sec.3091,Civ.C.) L0 Undoes Nsane , 7 z lenders Address U O ' I cvrify Net L haw read this application and note Nat the above idomation is [i.Pcones.I agree to comply with all city and county uNinencm and sue laws mating a Wilding construction.and hereby auNmim representatives of Nu city a enter upon the r{U37 show-menthmm l property fa inspection puryous (We)agree to an.indemnify and kccp hrtmless the City of Cup sauna against r y liabilidmjudgment,costs and expenses which may In any way acme against said City il- V? A PLLIICgANT UNDERSTANDS ANof the Saiding Of 11113 D WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. Re-roofs Signature of AppliaMConumaor Data HAZARDOUS MATERIALS DISCLOSURE Type Of Roof Will Ne applicant or future building occupsat more or handle huaoous material as chimed by the Cupertino Municipal Code.Chaplet 9.12 and the Health and Safety Code.secden 253334)? 0Yca ONO All roofs shall be inspected prior to any roofing material being installed. Will the applicant or future Width,occupant use equipment car dovices which If a roof is installed without first obtaining an inspection,I agree to remove it haurdone air camsaninsau a defined by Ne Bay Arta Air Quality Management all new materials for inspection. tria? ❑Ya [3 No 1 bane read the huardous materials mquitm us under'&per 6.95 critic Califon nia Hwl"SafctyCodc Succeed 255115.25533 and 35534.1 undersand thsa ifthe building dean not currently ham a seal that it is my responsibility an notify Ne occupam of de require==which moa be met prior in issuance ofa emdEcae Of Oceupamy. Signature of Applicant Date Owner or anthoerdagent Data All roof coverings to be Class an"or better • CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 34216128 . 00 DATE ISSUED. . . . . . . : 12/04/2008 RECEIPT #. . . . . . . . . : BS000006755 REFERENCE ID # . . . : 08120057 SITE ADDRESS . . . . . : 10695 MERRIMAN RD SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : SPARKS WILLIAM R AND JOAN M ADDRESS . . . . . . . . . . : 10695 MERRIMAN RD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-3923 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 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 C Of Fax(408)777-3333 OCUPEI,TINO Building Department JOB ADDRESS: 10695 MERRIMAN RD PERMIT# OWNER'S NAME: SPARKS,REED PHONE # (408)257-6435 GENERAL CONTRACTOR HOME DEPOT FAX# 425-814-9516 I am not using any subcontractors: '`� � 11/4/08 Signature Date Please check applicable subcontractors and complete the followmi 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: QF-12CO5� 000000 (office use only) i City Of Cupertino Building Permit Application E-Mail: Building-Permits CcDcupertino.org (Address is case sensitive). Jobsite Address: 10695 MERRIMAN RD Date: 11/4/08 Assessor's Parcel Number: 3412 IU 12-S'.00 Owners Name: SPARKS,REED Phone No: (408)257-6435 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: 9/30A O Worker's Comp No: 1928756 Expiration Date: 3/1/09 Carrier. AMERICAN HOMEASSURA City of Cupertino Business License No: Frppt%ed Credit Card Information Credit Card No: Expiration Date: 11110 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.