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08120059
CITY OF CUPERTINO 'P s xK;>;apaare s< '- ',. �'; BUILDING DIV'SION PERMIT CONTRrSCTOR�INFORMATION � v9R�x.f''mss v°�R �.`i .;3#�%•(,+Rub�'.'d°A$� � �YFr�'A BUILDING ADDRESS: PERMIT NO. 10142 COLBY AVE HOME DEP OWNER'S NAME: PERMIT ISSUE DATE CONTROL NO. (425) 6.36-7054 ARCHITEC/ENGINEEK BUILDING PERMIT INFO BLDG ELECT PLUMB MECH X00 LICENSED CONfRAC1OR'S DECLARATION U 1herebyaffirmWw tIl;con under provisions ofChamer9(commencing Job Description FF viN S.tion]0(lU)ofOivison 3afdm Btasircss and Profestians Cou.and mylicensc is ; Z in full a REPLACE GAS WATER HEATER '-� Dau Conlracur ARCHITECTS DECLARATION U I undersand my plans shall W used as public mantis n. o Licensed Professional 3 OWNER-BUILDER DECLARATION COO bunchy.(Erre on I am nempt from the Contracfemi..to,Code:My c Law de eCOO allowing won.(Soudan]031.5,Busum.mland ve. oli demolish. Any city ar county m_ which mqus u n pooh to con s the alar,im for m ermittof e a sir any stmctum uiy pearbslissuance,also rt to the theappluent for suchpetittofilea La (statement i€m< NIItptiacingwthS6aanlNNepmvivisNafNeCOmfYbraUccma ndProfssioro odLLY9 Sq.Ft.Floor Area Valuation (eommenringwiNSection mand)of Division the the egeinrvandpmfM favi Coda)or y�9 Nat k u exempt therefrom and the basis for the alleged evsnptiou Any violation of S449 Semon 7031.5by my.ppliant lm a permit mbjeeu the andiant u a civil penalty of APN Number Occupancy e Wt m..than five handmd dollan(S500). 31628031 . 00 p yTyp ❑I.uowrcs of tiro property,amY wployw with wagn'u the'v Ouawpensstion, will do dmwork and the swclum h ootinuMed oro@red formic(Sec.]ON,Busirtess and Profession,Code The Contractors License Law does enol apply to en own.of Required Inspections property who builds or improves downs,and who does such work himself or through his own emplowns,provided that such improvements we not intended moffeted for We.If. however,the building or improvement is sold within om yea ofcompletion,the owner, milder will have the burden of proving that M did rot build or improve for purpose of ❑1,u awtter of the property w,elusively contacting with licensed contactors to construct the project(Soc.7Os4,Busi mn and Professions Cade:)The Contractors U. is.'law does not appy to an owner of p.,my who Wilda or improves thereon.and. who contracts for such projects with a con omuo(s)licensed peram m to the Contractors License law. ❑Lwawptund.See .B&PCforddsmamn Owner Date WORKER'S COMPENSATION DECLARATION I hneby affirm under penalty of satiety oro of the following decluuionc I ham and will mainum a Certifmau ofConaent to self-imam far Works,Compan- ion,as provided for by section 3]W of the Lobar Code.for the performance of tite work for which this permit is issued. ❑I have and will maintain Worker's Compensation Imuran,,u mqumd by Section 3700 of the LAW.Code,for the performance of the work for which this permit is issued. My Worker,Compensation Imuran,artier and Policy number ere: Carrie: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thu seetim need not a completed If the pereit Is forom hundred dollars ISM) or Ica) I unify that In the performeam,of the work for which Ni,permit u issued,i shall not employ any perm.in any manner an as an become object to the Workeri Compemation U.,of California.Dm, Applicant NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should bncwe subject an,the Workers Compensation provisions of the Labor Code,you most vJ zforthwith comply with such provisions or this permit shall be d.med revoked. Zy CONSTRUCTION ION LENDING AGENCY Fw l hereby affirm that Nero u a construction lending agency f.the performance of C> the work for which this permit is issued(sec.3097,Civ.C.) W� Lenders Name .7 z Lenders Addw (.p Q 1 conify Net 1 have mad this application and sou that Ne above information is II.^ correct-1 agree N comply with all city and county ordinances and sum Ism relating to .Q(4.1: buildingconvection.and hereby authorizertpmse^uures of this city to enter upon Ne .hove-mentioned property for impcctim putposet 0. (Wc)time to Ove,indemnify and kup harmless the City of Cupertino against ren liabilitW,judgments.coats end a.,nonwhich req in any ways.agaimt said City V z APPuence of the swung of this pervoth. LLIICANT UNDERSTANDS AND WILL COMPLY WITH All.NON-POINT Issued by: Date SOURCE REGULATIONS. . Signatureof Appliav nVConactor pate Re-roofs HALSRDOUS MATERIALS DISCLOSURE Type of Roof WIII the apCmamdor futureipal Cgc.Chat ttstoworand ,math nmaarial u de,Sec by the 32(a)?m Municipal Code.CltaPmr 9.13,and tiro Hnith and Safety Code,Section zss3z(a>] All roofs shall be inspected prior to any roofing material being installed. ❑Y. ON. If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or future building by to B um e.Air Qu or devices which gr I hvudnm air cenumirunu u JCOnod by Ne Bay Area Air Quality Managemcm all new materials for inspection. Otric'? ❑Yen 0N S. I base mad Ne lumminus materials mmaimmenss under Chapter 6.95 of the Califor. nu FWlth&Safcty Code,Sections Z M5.25533 and 25534.1 mtluaatb do ifde building does not currently have a tnsn4 that it u my responsibility to notify dte occupOt of dtc myoimmenaWhich nous,xram prior missuance afaCertificate ofOccopmey Signature of Applicant Date Owner or mthamcd event Oeste' All roof coverings to be Class'W'or better CITY OF CUPERTINO • 4 ITEMS OF 28 PERMIT RECEIPT OPERATOR: suew COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 31628031 . 00 DATE ISSUED. . . . . . . : 12/04/2008 RECEIPT #. . . . . . . . . : BS000006760 REFERENCE ID # . . . : 08120059 SITE ADDRESS . . . . . : 10142 COLBY AVE SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : SUSAN SHIN ADDRESS . . . . . . . . . . : 10142 COLBY AVE 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 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ------------------------- -------- ---------------------------- 518 ------------------------- 518 WATER HEATER Community Development a_0_F_ 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 OCUPERTINO Building Department JOB ADDRESS: 10142 COLBY AVE PERMIT# OWNER'S NAME: SHIKSUSAN PHONE # (408)973-9956 GENERAL CONTRACTOR:HOME DEPOT FAX.# 425-814-9516 I am not using any subcontractors:_ '`" �` "" 1114108 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 Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile • Owner/Contractor Signature Date �81a� 000000 ' Permit No: (office use only) • City Of Cupertino.Building Permit Application E-Mail: Building-Permits((Dcupertino.org (Address is case sensitive). Jobsite Address:10142 COLBY AVE Date: 11/4108 Assessor's Parcel Number: -310 0 5 03 Owners Name: SHIN,SU$AN Phone No: (408)973-9956 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: 900-454-6955 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/la Worker's Comp No: 1928756 Expiration Date: 3/1/09 Carrier: AMERICAN HOME ASSURA City of'Cupertino Business License No: k%eA Credit Card Information Credit Card No: 4J1E0MWmmmW Expiration Date: 11110 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.