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08120062
CITY OF CUPERTINOx�«r I° ` BUILDING DIVISION PERMIT _CONTRACTURAINFURMATIQN BUILDING ADDRESS: PERMIT NO. 10231 MIRA VISTA AVE HOME DEPOT 08126062 ' OWNER'S NAME: PERMIT ISSUE DATE NE: A O. CONTROL N0. (425) 636-7054 ARCHITECTfEiGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 Op LICENSED CONRAC70BS DECLARATION L Wnby affirm Wt L w lirmnsrd carder provitions of Chapter 9 momommu., lob Description nzlm nc��rca7arx Busiv mmrum m. M mylcmu numREMOVE/REPLACE GAS WATER HEATER 3124 license Chis Ue.8 M y, q Dam.Convenor 704 ARCHITECTS DECURAT10N U 1 understand my plans must W mass u public records g C Licensed Professional 3 OWNER-BUILDER DECLARATION 'j e f I hereby a1.thou I am exempt from the Convector's License Law rat me O O following ream..(Section 70715.Business and Professions Code:Any city or county t m which requires a Permit to construct,mar.improve,demolish,.r repair any structure a=< Prior to its issuance,also roquias the applicant forsuch permit to rile a signed statement Nat he u licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation yO (commencing wins Stttion 7000)of Division]of Ne Businnss erd Professi...Cade)or .5$ that M is exempt therefrom and the basis for the alleged exemption.Any violation of $449 Section 7071.5 by any applicant for a permit subjects the millicent to a civil penalty Of APN Number Occupancy Type not mane than five bundled dollars(Sano). 35702032 . 00 P Y YP I,awnm o(theWaRrtY•mmy employees wins wagesadeir sole wmpensadon, wUl do the work and the swnum 6 rat immnded moRend forsale(Sm.7044,Butlws and Raresdons Cade:The Canvmmr's Limnse law arcs rat apply m an aw.of _ Required Inspections property who Wilds orimpmves themon,and who does suchwmk himselfor through his own employees,provided thatsuch improvements ea notinanded or Offered forsale If. however.me loading or improvement Is said within ata year of completion,the owner- Wilder will have the When of proving that Ie did not build or impreve far paTOse of sad.). ❑L as wrcr of the property me meluaively contracting wins licensed cutworms to constant the project(Sec.7044.Business and Professions Cade:)The Contsamm's V- «are law does ons apply In an owner of property who Wilds or improved memo.,end who contracts for such projects with a canaactm(s)licensed paramount as IW Convenor's L.leense Law. ❑Iamawpsuedm See .B&PCfmthumem. Owner Dam WORKER'S COMPENSATION DECLARATION 1 bereby affirm order porosity of perjury ons of me following declarations: 1 ham and will maintains Certificate ofComent 10 self-imurt fa WerkeYsCompen- 'on,an Provided for by Section 3700 of the Lahur Code.fm the pufoweno:of the work far which this permit is isued. ❑I have and will munud Worker's Compensadon Insurance,as required by Section 37W of the labor Code,for the perfmmmcc ofine weark for which this pewit is issued ' My Worsils Compensation Insurance carrier and Policy number ere: Caries: Policy NO.: CERTIFICATE OF IE EMP ION FROM WORKERS' COMPENSATION INSURANCE (Thu section teed an,W completed if are Permit Isfm one hundred doRan(SlIXO or less) I cmtify mot in me performance of me work fur which this persalt ls issued.I shad!not emplo,any parsem in any mannans u to became subject to dm Worken'Compmeatien Laws Of Cadiforols Dam Applicant NOTICE TO APPLICANT:If,after making this Certificem of Exemption,you should Weems subject in the Wafer's Compensation provisions of the labor Cada,you must ,J z fmthwith comply with each provisons or this permit shut he Maned revalued CONSTRUCTION LENDING AGENCY [-+ I hereby affnn taut them is a commuction lending agency for the performance of a > me wart fm which this pewit is issmd(Sec.3097.Civ.Ca Qlender's Name , z Ltndefs Add. U Q 1 cmdfy met I have rod this impliesvan sad state ma are abuse termination u IT. F canons.I agree to comply with JI city and county oNinarces and sum laws misting to D U Wilding convection,road hemby summon mprtsenuuves of this city to enter upon the r W alave-mentioned property fm irvpcnion purposes gy (Wc)agree to ave,indemnify and soup hormkss the City of Cupertino against F'r ti liabilities judgments.cots and expenses which may in any way tame against sad City U z in consegrcnce of the granting of mu permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. Re-roofs AC Signaun OfAMficism/Conumsetor Dae HAZARDOUS MATERIALS DISCLOSURE anal Type of Roof Will the applicant or forum Wilding rcc Chapter or andd i h eardoanmamriai u defined by de Cupenirw Municipal Coo,Chapter 9.13,and uhe Halm and Safety Cade,Section 2553247 All roofs shall be inspected prior to any roofing material being installed.❑Yes 0N Will the applicant or Noun,building Occupant me mulpment or aevirca which If a roof is installed without first obtaining an inspection,I agree to remove it hextemons oar contaminator a Jerined by the Bay Area Air Quality Management all new materials for inspection. sv m7 ❑Yes [D No I have real da hanrdoua materials mquimmcnts under epar6.95oftheCalifm- .is Health&SafetyCoM,Seem.25505,25533 and 25534.1 understand itself the Wilding does nut currently have•tenant mat It is my nuponsibiliuy in mol,the occupant of the requirements which must In met Poor to issuance Of a certificate Of Occupancy. Signature of Applicant Date Ownm or mthomad agent Dam All roof coverings to be Class'W'or better CITY OF CUPERTINO • 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35702032 . 00 DATE ISSUED. . . . . . . : 12/04/2008 RECEIPT # . . . . . . . . . : BS000006757 REFERENCE ID # . . . : 08120062 SITE ADDRESS . . . . . : 10231 MIRA VISTA AVE SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : XIAO HUANG ADDRESS . . . . . . . . . . : 10231 MIRA VISTA RD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2704 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 0 Torre Avenue Cupertino CA 9 014 Telephone(408)777-3228 C OF Fax(408)777-3333 •CUPEkTINO BuRding Department JOB ADDRESS: 10231 MIRA VISTA ROAD PERMIT # b � oo�a OWNER'S NAME: HUANG,XIAO PHONE # (408)391-1630 GENERAL CONTRACTOR:HOME DEPOT FAX# 425-B14-9516 I am not using any subcontractors:_ '`�'. /L� " 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 Permit No: 08' i 2. ODM Z 000000 (office use only) City Of Cupertino Building Permit Application • E-Mail: Building-Permits(cDcupertino.orcI (Address is case sensitive). Jobsite Address: 10231 MIRA VISTA ROAD Date: 11/4/o8 Assessors Parcel Number: '35-7 02 D3Z OU Owners Name: HUANG,XIAO Phone No: (408)391-1630 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: 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: 9/3040 Worker's Comp No: 1928756 Expiration Date: 3/1/09 Carrier: AMERICAN HOME ASSURA City of Cupertino Business License No: {Yn\�ec1 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 contractor/subcontractor form need to be submitted with each permit.