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12020044 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 943 MILLER AVE CONTRACTOR:WATER QUALITY PERMIT NO: 12020044 PLUMBING OWNER'S NAME: LYNN BUCHOLZ 1860 ALMADEN RD DATE ISSUED:02/09/2012 OWNER'S PHONE: 4082472882 SAN JOSE, CA 95123 PHONE NO:(408)267-9330 ❑ LICENSED CONTRACTOR'S DECLARATION i #.... BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lie.# 5e,5 / MECH RESIDENTIAL COMMERCIAL Contractor s` Date JOB DESCRIPTION: REPLACE WATER HEATER I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: 1 have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$4300 I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for whit this APN Number:36919049.943 Occupancy Type: permit is issued. �� APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY FROM LAST CALLED INSPECT ON. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of thea granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. ' RE-ROOFS: Signat `� Date All roofs shall be inspected prior to any rooting material being installed. If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25.505,25533,and 25534. 1 will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with theCup ino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectio ,25533,and 25.534. Section 3700 of the Labor Code,for the performance of the work for which this _ Owner or authorized agen . Date permit is issued. I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date Building Department City Of Cupertino •' 10300 Torre Avenue Jim Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: �! � � �- ;�� PERMIT# U OWNER'S NAME: PHONE GENERAL CONTRACTOR: BUSINESS LICENSE �`/ ADDRESS: f �'�iG`, C, -� CITY/ZIPCODE *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCO TRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. 117 47 I am not using any subcontractors: — 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 Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date CITY OF CUPERTINO 6 ITEMS OF 13 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 36919049 . 943 DATE ISSUED. . . . . . . : 02/09/2012 RECEIPT # . . . . . . . . . : BS000015974 REFERENCE ID # . . . : 12020044 SITE ADDRESS . . . . . : 943 MILLER AVE SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : LYNN BUCHOLZ ADDRESS . . . . . . . . . . : 943 MILLER AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : LYN SATALINO CONTRACTOR . . . . . . . : SATALINO, MARTY LIC # 21526 COMPANY . . . . . . . . . . : WATER QUALITY PLUMBING ADDRESS . . . . . . . . . . : 1860 ALMADEN RD CITY/STATE/ZIP . . . : SAN JOSE, CA 95123 TELEPHONE . . . . . . . . : (408) 267-9330 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1 . 00 41 . 00 0 . 00 41 . 00 0 . 00 1BCBSC VALUATION 4, 300 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 4 , 300 . 00 0 . 50 0 . 00 0 . 50 0 . 00 1PPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 1PRWHEATR UNITS 1 . 00 26 . 00 0 . 00 26 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 156 . 50 0 . 00 156 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 325 . 36 amex --------------- TOTAL RECEIPT 325 . 36 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 518 WATER HEATER GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION MEP 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228- FAX(408)777-3333- building6i�gupertino.org MISC l 20 "LING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT D�tFSS r-, . APN# u 1 �r qq3 ,/)j.,4 L Y..� 0/Z I� OWNER N PHONE E-MAI L 41 STREET ADDRESS CITY, STATE,ZIP FAX CONTACT NAME PHONE E-MAIL wa/-z! STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT L1'CONTRACTOR ❑CONTRACTOR AGENT ❑ ARc=cr ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LIC SE EI; L CENSE TYP� BUS.LIC# ✓ i COMPANY NAME E-MAIL FAX STREET ADDRE$ ., � _� �� T YATE,ZIP � � / � � PHONE _ -�,i L14a044- i C lJ ARC=CT/ENGINEFR NAME a/ LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WII-DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES Bt=ING: ❑COMMERCIAL URBAN INTERFACE AREA SIXO FLOOD ZONE PO EIC 9-M HOME? 8-14 DESCRIPTION OF WORK TOTAL VALUATION: V /�(� RECEIVED BY: By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provide is correctj have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relati g to 'ldin onstruction'6'I authorize representatives of Cupertino to enter the above-identified property for inspection pu@oses. Signature of Appl cant/Ag ��> �i Date:7-7 " SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY l3 OYER-THE-COUNTER c ❑ EXPRESS U w ❑ STANDARD U ❑ LARGE ❑ MAJOR A EPMucApp_2011.doc revised 06/21111