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08120064
CITY OF CUPERTINO g BUu.DINc DIVISION PERMIT fRC�t�ITRA.CTQ,R I1k'ORMA'I±I -.�. RUILDINGADDRESS: - PERMIT NO. 10980 KESTER DR HOME DEPOT OWNER'S NAME: PERWT ESUS DATE T A CONTROL 110. (425) 636-7054 ARCHTTECrfeNOINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 u o ZD LICENSED CONTRACTOR'S DECLARATION Ib Description Vi FF�,{ hereby eby&(firm Nam at 1 licenlicensed! O05CO under Provisions of Chapter 9(commencing p n<S with Sanest 7M)Of Division 3ofthe Business W Professions Cade,and my licenscis _oh in fall farm and affect. REMOVE/REPLACE GAS WATER HEATER , ppz License Class Lm.g c— Dam Couracwr ARCHfrECrS DECLARATION 1 understand my plans shall be used as Public mends Ddu g 0(n Licensed Pmlcssonal i' z OWNER-BUILDER DECLARATION cortm0N �1 I emby alum that 1 1. exempt from the Cantmcm o Any c law for the co following moon.(Scorn]construct, Business r and Pmrusiuv Coda:Any city or county $ which acquires&Permit to acquires alcor.aforsu h Perliad.oraliAor mash any sbmcrum _Zy priwmiu issuance.also acquima the aPPlieanrforsueh permit ran file asigOuJ aamment E G that he b liccmed puraunt to the provision of Una Contractors Liccnx Law(Chapter 9 Sq.FI.Floor Area Valuation �a (commencing with Secure,7000)OfDivision 3ofthoBusasarad Profea onsCres)or 449 Q`t Nat he u exempt thrafh u rom and the basis for tlegassumption.ption.Any violation of Section 7031.5 by any applicator Inc a permit subjects the applicant m a civil penalty of AFN Number Occupancy Type Our mom that low hundred dollars(M). 35628012 . 00 0 I,u owner of the Property.as my employees with wages as their sole compewdem. will do the want and the structure b Out mundd ar onemd for safe(Sar.TO44,Bahamas and Pmfessiom Cade The Cmtracrors Uccme law dem Dot appy m an owner of _ Required Inspections Property who buildsmimprowsthermn,and whodatasuchwork himselfor through his awn employ=,provided Narsueh improwmau am an,intended woRered fwnle.IL however,de building or improvement is sold within ane year of completi(n,the Owner- builder wnerbuilder will haw tie burden of proving that he did Our build or improve for Purpose of sale.). 0 1.m marc of the Property-w exclusively cmuuvng wide IiIXmad conunan te OunsuM the i alem(Sec 7044.Business and professions Cade:)The Contractors U. come law does not appy no an Owner of property who builds at improws Burma.and, who contmcu for such projecm with a conuamar(s)licensed pursuant m the Contractors License law. 0 lamexetnptunderSm .B&PCfwthismsson Owner Date WORKERS COMPENSATION DECLARATION I hereby sainn under penalty of perjury,am of the following declsrmemor have AM will maintain a Certificate of Comenr to self-iuum far Workers Campen- 'm.as Provided far by Seem.3700 of ran tabor Code far the pesommna of the wort for which this,permit is tared. O 1 have and will mummy Worker's Compensation Immance.as acquired by See m 37M m(tha Labor Code,for Ne perform&¢of than work for which this permit is issued. My Workers Compensation Ins rang aniw and Policy number am: timer: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE rTIa.edm need Out coomplowd time permit is foroOu hundred dollars(SIM) or loss) I century that in am performance N the wort fw which this permit is humid.l fall not employ any pe.to any ex rrou m become subject In the Workers'Compensstim Laws of California.Dam Applicaa NOTICE TO APPLICANT:IL after making this Ccninate of Exemption.you should become subject to the Worker',Compmsatia provisions of the Labor Code,you most wJ O forthwith comply with such provisions or this permit Nall bmro e deeed oked- z CONSTRUCTION LENDING AGENCY [—i Ithereby afflm that Nem is a comsmtim landing agency for de performanec of CL vim„ the work for which this Permit b issued(Sec.3097.Civ.C.) W A Lenders Nano , jz Lenders Add. U O 1 certify that I haw rad dos spplicatim and sum hard the above infotmmon is [s.f' cmrcm.I agree to comply with all city and Canty wdinaees and sum laws misting to U building construction.and hereby stabona reprmmodim of this city to enter upon de W aWw-matiamd pmpcny for inspection purposes G (We)agree to saw,indemnify and keep harmless to City of Cupertino against (q liabilities,judgments,cuss and expenses which may in any way accrue against said City U,z ineanxquerace,of the standing of this permit. .. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. Re-roofs Signature of Al plicardConuacto, Data HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future Wilding occupant Vose orhandle hazardous materia as defiled by to Cupenbm Municipal Code.Caper 9.13.and the Health and Safety - Code.Section 25531(q7 All roofs shall be inspected prior to any roofing material being installed. OYm ONO Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove t havardous air contaminants as defined by the Bay Acta Air Quality Management all new materials for inspection. amm7 ❑Ya ONO I have mad Ne hvardau maeri&b mquimmem under&f mr6.95 ofdm Califor- nisHealth&SafnyCde.Sections 25505.25533 am125534.1 understood tmiftm building does Out currently haw a terms,the s it is my respomibiliry,m notify the occupant Of to myuimencnts whkh moa eend,priarm tssuarec of a Ccrmicme of Occupancy. Signature of Applicant Date Owner ormthorivadagaw Dam All roof coverings to be Class'n:t'or better • CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 35628012 . 00 DATE ISSUED. . . . . . . : 12/04/2008 RECEIPT #. . . . . . . . . : BS000006759 REFERENCE ID # . . . : 08120064 SITE ADDRESS . . . . . : 10980 KESTER DR SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : HOELSCHER DONALD G AND NANCY J ADDRESS . . . . . . . . . . : 10980 KESTER DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-3916 RECEIVED FROM . . . . : JEFF JORDDAN CONTRACTOR . . . . . . . : FRANK BLAKE LIC # 30610 COMPANY . . . . . . . . . . : HOME DEPOT ADDRESS . . . . . . . . . . : 12601 132ND AVE NE CITY/STATE/ZIP . . . : KIRKLAND, WA 98034 TELEPHONE . . . . . . . . : (425) 636-7054 SFEE 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 al Cupertino CA 9014 Telephone(408)777-3228 Fax(408)777-3333 •CUPEkTINO Bnfldin . Department JOB ADDRESS: 10980 KESTER DR. PERMIT# O91 l0 OWNER'S NAME: HOELSCHER,DONALD PHONE# (408)257-6836 GENERAL CONTRACTOR:HOME DEPOT Y� FAX# 425-814-9516 I am not using any subcontractors:_ Cc'a r� �lc ,,4*,aP 11/4/08 Signature Date Please check applicable subcontractors and complete the followina 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: M 12 OOLDq 000000 (office use only) City Of Cupertino_Building Permit Application O E-Mail: Building-Permits(cDcupertino.org (Address is case sensitive). Jobsite Address: 10980 KESTER DR. Date: 11/4/08 Assessor's Parcel Number: 35-cp 2g D12 .00A Owners Name: HOELSCHER,DONALD Phone No: (408)257-6836 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: 9130/10 Worker's Comp No: 1928756 Expiration Date: 3/1/09 Carrier: AMERICAN HOME ASSURA City of Cupertino Business License No: Credit Card Information Credit Card No: NIM&MR88 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.