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081201240� zC a= Dom. G UC UC OE FG Us CITY OF CUPERTINO T,vT��Isa,,ggT�T BUILDING DIVISION Pg�1�lYulCONtgwdtOR*INF(TRM°ATIO:N R BUILDING ADDRESS: PERMR NO. 21079 GRENCLA DR AFFORDABLE W21TER HFATRES & 08120124' OWNER'S NAME: PERIbm SUE DATE PHO , • SA CONTROL NO. ARCHITECTiENGINEER: BUILDING PERMITINFO bk RMV RPLC WTR HTR 75GALS BLDG ELECT PLUMB MECH D O O O LICENSED CONTRACIOR'S DECLARATION Job Description P I hereby affirm Nat 1 am licensed under provisions of Chapter 9 (commeneug with Section 70M) of Division 3 of ft Business and Professions Code, AM my liecom is lomummeaMerc 27 G . ata 1 LY. g Date Comnmtar� ARCHITECTS DECLARATION I uMcmand my plans shall be mead As public records LIttM1Yd PNfesporiA OW NER-BUILDER DECLARATION 1 barmy sfFMA that 1 am ucm,I from the Cenvoctoe, License Law for the fallowing moon. (Section 7031.5, Business and Professiu s Code: Any city or county which mquima A permit in mauunt, altar, improve, demollah. or epair any nevem prior M its issuance. also requites the applicant forsuch permit to file a signed statement that he M liccmmd pumuant to the previsions of the CommetorY Lkoom law (Chapter 9 Sq. Ft. Floor Area Valuation (commencing with Secuon 7") of Division 3 of the Businm And ProRssions Code) or that he B exempt therefrom and the basis for the alleged exemption. Any violation of APN Number Occupancy Type P y yp Section 7031.5 by my applicant for a permit subjects the applicant to • civil penalty of not mom wan fin hundred dollar ($500). ❑ 1, u owner of the pmpeny, m my mploym with warn m theh sole compemuon, e aired Inspections will do the work. And the swore iano, intended or offered forsale(sec. 70", BusinessR And pm(esslov Code: The Cenaacmea U. Law dm net apply M An owner or 9 P property who builds on i mprovu Oercon, aha who does such wank himself or through his Coast ceploym. Provided thatsuch improvements arc not inMMed eroffertd fm We If. however, this building or improvement usoid within one year Of cmplmen. the owrcr- builder will have de hurdcn of proving that he did not build or improve for pumper of sale.). ❑ I. As owner of he property. Am exclusildy cenymtinr with licensed mnrsmmrs An covtvct the project (Sec. 7044. Business AM Profession Code:) The Connors U. cense Law dm not apply M an owner or property who Wilds Cr improma thereon, and, who contests for such pmjem with a conaisamr(s) liaved pursuant to the Comracmes License Law. ❑ 1 am uempt under Sec. . B k P C for this msson Owner Data WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following decimations: 1 have and will mainuin a CertificaM of Covent to self4risum fm WmlmeaCompcn- cation, As provided for by Sesven 37M of the Labor Code. for the Performance of the wank (or which this Permit is issued. ❑ I have AM will maintain Woskces Comperet Insurance, as required by Seamon 13700.17 the Mbar Code. for we pe finance of the work for which this permit is issued. 11M, Workers Compev1atian Inmranme caries And Policy number art: � b % f �7 rte. CsMen .Y -L f"l/ Policy NZ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not he compked i(the Permit Is for one hundred dollars ($100) nr loss) I certify the. in the Perfemunre of dm work Tor which this Permit Is issued. I shall rat employ any Person in any mannerm As in become subject M the Workera Compcnudon Laws of California. DAM Applicant NOTICE TO APPLICAFIT: If. a1mr making this CertirscaM of Exemption, you should become subject M the Workers Compensation pmisiau of the Lobar Code, you most ' foMwiw comply with such provision or mix Permit shall he deemed mmked. CONSTRUCTION LENDING AGENCY 1Mr for ore Perrormancear that them issued whirr the week for which tw Permit B is4aca tsec. Som, civ. e.) sceumnldmwng.) lenders Name , Lenders Aadnm 1 certify that I ham rad this application and sum that the Alamo information is ' • connect I agree to comply with all city and county ordinances and sue laws totaling to building convection, and hereby mthorim representatives; of this city to enter upon ted ahove-mentioned property for ivpecuon puymses (We) agree to an, indemnify and kttp harinless the City of Cupertino against j liabilities, judgments. costs and expenses which may in any way sector against mid City r of the Fanning of Nis permit ' AUNDERSTANDS ANy.WiCL COMPLY WITH ALL NON -POINT APPLICANT �/3 CG Issued by: Dale L� SOURCE REGU S. 9 / I-�ffow Re -roofs �. Type of Roof Signatureor Appi�pn aARDOr Dow HAZARDOUS MATERIALS DISCLOSURE Will thea, m forum Wilding empanlsam m handle h material As Cupertino Heald, A de Cupertino Municipal Cade, Clupmr 9.11, and the Health aha Safety ca. Sed io Coca. Section 255324)t [3 Y. All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without firs[ obtaining an inspection, I agree to remove Will Nc applicant or Lover building aavpam use equipment or dew MCA which emit harardnu air conuminama As defined by the Bay Area Air Quality Management all new materials for inspection. Diems@ QYv Nu I ham reW the hmafwnm maerialsmquimmcnu under Chepterb.95 of the Califon- 'rias Safety Cadc. 155lland15534.1 thaccup Wilding motiomint it to nournd dm Mimi a tenant that it u my responsibility m now'y the occupant of the Mimi Mqultemcntswhi A W tpriorMis.cfacenict,f«�mp,nry/ Signature of Applicant Date � 7Z/ /S /, All roof coverings to be Class 'ns' or better Dam Owner or authorised agent 4 ITEMS OF 12 CITY OF CUPERTINO PERMIT RECEIPT • Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32628007.00 DATE ISSUED.......: 12/19/2008 RECEIPT #.........: BS000006863 REFERENCE ID # ...: 08120124 SITE ADDRESS .....: 21079 GRENOLA DR SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OWNER .....:......: MR. LI ADDRESS ..........: 21079 GRENOLA DR CITY/STATE/ZIP ...: CUPERTINO, CA 95014 OPERATOR: patg COPY # : 1 • RECEIVED FROM ....: EDDIE D NALLEY CONTRACTOR .......: LEONCE ROUX LIC # 26850 COMPANY ..........: AFFORDABLE WATER HEATERS & ADDRESS ..........: 24707 RAILROAD AVE CITY/STATE/ZIP ...: SANTA CLARITA, CA 91321 TELEPHONE ........: (661)259-7131 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL ---------- •1BSEISMICR - ---------- VALUATION 1,800.00 -------------- 0.50 -- 0.00 0.50 -- - --- 0.00 IPPERMITFE 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 WATER HEATER -------- ----------- ----------- • CITY OF CUPERTINO f 0 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax(408)777-3333 Building De artment JOB ADDRESS: 21 b?q 6re, mle, r) V/- PERMIT # 0e/ 20 n-11 OWNER'S NAME: Gtr,/ PHONE # t/di- 7z -i763 GENERAL CONTRACTOR +rjyp4 0 FAX # I am not using any subcontractors: 2 Signature Date Please check applicable subcontractors and complete the following information: 60 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 /2 Date CITY OF CUPERTINO WATER HEATER CUPERTINO PERMIT APPLICATION FORM 3z�-z �-6o-1_ �o L'J Revised 6/16/08 APN # Date- O iZ1►�►sy Building Address: 21U -7q GrA&Va1 !� Owner's Name: Phone #: h�(L L 6,�- Contractor: Phone #: (, 6 t - zs 1� 7) 7 i ��pf�A(�1Q- W�� •ca�-rI Fax #: Cupertino Business License #: Contractor State License #: (,rL 3(�$ Contact: Phone #:,' sCo-P Fax #: Building Permit Info: 11 Bld ❑ Elect Z Plum Mech Residential Commercial ❑ Job Description: Strapped On Platform Bonded New Location ❑ Replacement Valuation (cost of project): (gGU _ Project Size: Express ❑ Standard Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Green Building Points achieved: L'J Revised 6/16/08 CITY OF CUPERTINO Lot, WATER HEATER nOF CUPEkTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group Permit Type 1PCWHEATR Commercial Water HeaterNent B PCWHEATR 1BSEISMICOM Seismic Commercial B I RWHEATR Residential Water HeaterNent B PRWHEATR 1BSEISMICRE Seismic Residential B 1PPERMITFEE Plumbing Permit P 1TRAVDOC Travel & Documentation B 1BUSLIC Business License B lJ 9