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08120061 CITY OF CUPERTINO w+ a' ,g `7,777, BUI LDING DIVISION PERMIT *�CO1�I'TRAGTOR'.INF(:IItMAr�ION ' • I. 3 ar.�-w`S'F, .....sxu�`,rsf„ie end 5z* .m" ,..a.^�^�+ ' BUILDING ADDRESS: PERMIT NO. 10186 DANUBE DR HOME DEPOT OWNER'S NAME: PERMIT ISSUE DATE f AT T OTT NE q CONTROL N0. 4 . O (425) 636-7054 ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH u00 LICENSED CONTRACT'OR'S DECLARATION Job Description �UF 1 bmeby afam that 1 am imcasod undo provisions of Chapw 9(commcncing 2ty wId1SCLlion 70M)Of Division 3 ofdm Business And Pra(CSLano Cade.and my lKmt4 is infullfancande(rea. REMOVE/REPLACE GAS WATER HEATER , u�Z License Class U.Y Dau Contractor ARCHITECTS DECLARATION UI mtdcuund my plata shall be used as public mcords CA 4O G Licensed Profcon sdal 5 OWNER-BUILDER DECLARATION 1 Wmby.Inco the 1 A.1. wcmpt from u r Cssion o I:Anyo Lew far the p o which me mason.(Saxon co I.S.Busmen and Pm.dcdons Code:Any city m scum, z m which mqulma•pmmh m mwtmee alar.improve.demolish,at mpsir uY umnure - Zn patlacr 0ilrccumalpuchan'toiOn dm,isions.fthe Cellpermitmicc.la Law (Chap.9 X59 (comm Hcingwi Sers mutWpmvivions3of cBusinwsmd nclaw(Clupur9 Sq.Ft. Floor Area Valuation y'r$ (commcncing pthameian 700E of Divisian3 of theiwiness andon.Any 449 Nat k u exempt tan^Irate and Oe btu for the Ylegd eumptim.Any viomtion of Sccion 7031.5 by any applicant(a apermit subjecs On applicant o a civil PewltY of APN Number Occupancy Type An,mac than me hundmd dollar'loam' 36951006 . 00 ❑1,as awrcr Of the WOPf'+rY,IX mY wploym with wago as uev sole wmpenAsum, will do the wok and do.ommso is not imendcd or oRnrd Immix,(Sec.70m.Busiaas Required Inspections and Profeasioru Calc Than Contractors License Law dors ae ns nal apply As an Mar of tl P property who builds or improve thmeon.and who does such work himself m duough his own cmplaym,promind Out such improeemms are not bounded or ortud(orale.If. however.On building or'unpravement is sold within ors year of cumpleum.ft currier- builder will lave the bunds of pmving Oat K did not build or improve for purpoa of Asia.). 1,as owner of the properly,em exciusimiy contracting with licensed contractors In cunssamt the projm(sec 7W.Bwincn ad ProRcsions edea)The Cantrumrs U. cc=law dm Out apply to an owner of property who builds or impmwa Demon,and. who contracts for such pojcros with a consanor(s)Iicewed pursuant to Ne Contractors Lmeme law. ❑lamaemptunder See ,B&I`Cforthismawn Owner Dau WORKER'S COMPENSATION DECLARATION I hereby affirm under pendly of perjury arc of the following declatdorn, "I ham and will maintain a Cesulicate of CW Cannot m self- arm far Worker,Camprn m,as provided for by Section 3Taa of the Mbar CO .for the perfomaoa of the work for which this pcmit is ivued. ❑1 have and will maintain Warker's Comperu,dun Ia.u raluird by Section 377aa a Me War Cade.for the pdmmancc Of the work for which Of, .I,is iasad. ' My Workers Compensation Insurance carrier and Policy number art: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE (nuscctm sand Out be complowd Ute permits foram huMrtddollars(SIM) or law) 1 cmtify that M the pmformarce of the wah for which this pmmit is basad.l shall era employ any person in any meuarso as to become subject in Ur.Workers'COmpe andm Laws of Califamia.Dau Applicant NOTICE TO APPLICANT:If.after making Nu Ceniftcam of Exemption,you should became subjem to the Worker's COmpensetim provisions of On TAbor Cade you most O Z faMwiOt comply with such Provisions or Nu peroii shall be decmed remand. Z„ O CONSTRUC ION LENDING AGENCY [-a Ibemby Affirm that Here is a connructim knding agc y far On Tefformarrce Of (Yi> Ne work rat which this permit is isad(Sce.IM.Co.C) Qlsnders Name , .7 Z Lcdera Add. U O I mMfy Nal 1 have mad this pplication and stain Nm the above information is F comas 1 apo to comply with all city std cowry mdiraans,d sum laws Elating In O U building connotation,and hemby authadu mptoenuti ,or this city to enter upon Oe r aMve-menuoad property,rot inspection purpuras y (Wc)agme to urs,indemnify and kap harmlm the City of Cupertino against F'rq liabilities.judgmenu.comandexpenms which may in anywayaecmc againstuid City U Z to consequence of the graining of than pemil APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. Re-roofs Signarum of ApplinHAZAREcmr Dau HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will that eCuperApplicant mforumbuilding accupanummor handle HcAlOaasmamrial As adfirml byStation the Cupertino Municipal Code.Chapmr 9.13,roti On Hwlth and safety Coca.SeNansss3z(a)+ ❑Yrs 0N All roofs shall be inspected prior to any roofing material being installed. 4hkI IW applicant or comm Wading occupant usc cquipmmt Or devim which If a roof is installed without first obtaining an inspection,I agree to remove I haWO. ow air commons u a dcftad by the Bay Arca Air Quality Mmagemcnt all new materials for inspection. u cd ❑Yes ON. yy' I have foal de hvardau nwcriamnyuimmcnu mor Clupmrb.93 of theCalifor- niaHcahh&Safmysumasccuow255aS 3myrspo 2353x.1 to nournd nacum Wilding dm rot cumnOY haw•¢Wane than it u my responsibility m tmtifY Oe occupant of the requimmenu which most be mel pilar m isuanca of a Cenifeam Of Occupancy. Signature of Applicant Date Owar or am caned,sent Dam All roof coverings to be Class'%W'or better • CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Seo: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 36951006 . 00 DATE ISSUED. . . . . . . : 12/04/2008 RECEIPT #. . . . . . . . . : BS000006756 REFERENCE ID # . . . : 08120061 SITE ADDRESS . . . . . : 10186 DANUBE DR SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : CHI LOU ADDRESS . . . . . . . . . . : 10186 DANUBE DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2140 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 O Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CI OF CUPEf�TINO Fmc(408)777-3333 � -� Building Department JOB ADDRESS: 10186 DANUBE DRIVE PERMIT# oolo OWNER'S NAIYIE: LOU,CHI PHONE# (406)605-1067 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 following information: VF 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 000000 Permit No: D�'12 i�CA j (office use only) City Of Cupertino Building Permit Application O E-Mail: Buildinq-Permits(cDcupertino.org (Address is case sensitive). Jobsite Address: 10186 DANUBE DRIVE Date: 11/4/08 Assessors Parcel Number: 3(Dq 51 OOLn .b 0 Owners Name: LOU,CHI Phone No: (408)605-1067 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: 9/3o/lc Worker's Comp No: 1928756 Expiration Date: 3/1/09 Carrier: AMERICAN HOME ASSURA City of Cupertino Business License No: 6pek,ect Credit Card Information Credit Card No: 005130INNIMMW 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.