08110070 CITY OF CUPERTINO
BUILDING DIVISION
PERMIT CON TRACTOR�IIORMrA�ION
BUILDING ADDRESS: PERMR NO.
21001 SEVEN SPRING PKWY WATER HEATERS ONLY 08110070
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SA CONTROL NO.
ARCHMCOENGINEER: BUILDING PERMR INFO
REPLACE WATER HEATER 50 GAL BLDG ELECT PLUMB MECH
0 0 0 0
goo LICENSED CONTRACTOR'S DECLARATION ENERGY FACTOR . 58 Job Description
in� I beeby arum tot I am Iwamoto motor provisions of Chapter 9(ammencinj
;� who Sccdon 70110)of Division 3 afore Business and Pru(eseiamo Code.and my liccnte is
I.full forecasts off 1.
jLieme. las Lk.M ,
07
p Dam — — ' Conaxra
7W CHRERS DECLARATION
U 1 udersund my plans shall 4 card as Public moods
anpr^ Licenwd Professional
5 OWNER-BUILDER DECLARATION
1 hereby alum Nat 1 am exempt room we ConuaemYs License Law for the
CO O following mason.(Section 7031.5,Business and Prefcssiov Codc:Any city or county
$ which requires a permit to covunaL alcor,improve.alarmism.or repair any structure
Iy prior m its iuuame,shm requires ore applicant for such permit w file a signed aammem
.c that Mis;Boosted pur IWthcprovisions;ofthe conwcmrYlucnxLaw(Chapmr9 Sq.Ft.Floor Area Valuation
y�$ (cmnmcrrdng with Section 7000)of Division 3 of the Business and professions Code)m
s, — lore he uexempt therefrom and the basis fee was allegd...mpJat,Any violation of
Section 7031.5 by airy applicant for a pound,subjects the applicant to a civil penalty of APN Number Occupancy Type
not mart than But hundred dollars($.100).
OI,um=ofJxpmpeMerrmyemployeewithwagesu Weirmkcampe dw.
will do twwork.and ore structwe is notinunded moQered forsato(Sm.7016.Business Required Inspections
"Promsdona Cade:The Conttw.7ors Liartse Law doe not apply w eco owner of q p
properly,who Wilds or oroposes therron,ad who does smth work himvlf m Jbough his
awn employees,provided them each impowments an,not imen l d maaavd(orale 11.
however.the building m Wpmwmmt is sold within now Year of cmnpledcn.ore comes,
Wilder will have the burden of proving Nat he did trot build car improve for purpose of
sale.).
❑1.as owner of the property,am exclusively contracting with licensed ounwcwn w
rovaoct the pjee(See.7066,Business ad Profeammet Cade:)M Cesm-cures U.
ave law does am apply an an mmer of propctty who boilds at improver oreman.and,
who contacts for such projects with a eamranor(s)located purport w We ConuxmYs
Lkeve law.
❑lamaereptundct See .B&PCfor Jdsnason
Owner Dam
WORKERS COMPENSATION DECLARATION
I bemby dr, unhr penalty o(prjmy mm o(Jm following declarauanc
I1 Mm and will maintain a Certifiaue of Covent m self-mama rot WehcYs Cooper,
on.u providd fm by Section 3700 of Jct labor Coe,far the prfmw.of the
work for which this permit is issond.
19have and will maintain workers Compensation Ivurana,as required by Section
9100 of the Labor Code,for the performance of the want for which this Permit is issued. '
My Workers C!oom�3pnWion w.�mnpmse carrier and Policy number are:
Carrier Xa�1J-sT J'1 Policy No.: yS d 5-01/9
CEknFlCATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
rnissoomm need]nothecmnpleted Bthe Permit is(mane hundred dollen($hill
or less)
I century that in the performance of we work fm which this permit Is issued.I shall trot
employ any penin in any noaorcr m as m become sobject to the WorkersCompnsaJon
Laws of California.Dam
NanCm
NOTICE TO APPLICANT:If,ager making n p GCNBCaof of Exemption,you u must
baame subject y it Workers Compensation provisions of the Lahm Coe,you muss
.J O forthwith comply with such provisions or this Permit shall w oared mvokco.
z'-" CONmucr1ONLENDDICAGENCY
F-M moor-M I berate,afBmn that Jam u•emnoncunn kndingaparry far new permmana of
!Yi > the wars for which this permit is issued(Sec.3097,Civ.C.)
1 Lenders Name
Z z Landers Address
U C) 1 anify dist 1 have mad this application and sum don tw above information is
correct,1 agree w comply with all city and county ordimentts and sem laws mlatng w ,
� building concentrated.,and hereby audwriec reproacnutivu of this city w enter upon ore
above-mntioned property for inspection purposes.
4 (We)agra to ave,idcmnify ad kap barmlea the City of Cupertino against
MF'y(n liabilides,judgments.case and caPeves which may us any way acme against said City
U2
in comoschwncc of the granting of this permit,
�^ So LIC UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date �.
SOUR ULATION .
� ? H� ek2w � Re-roofs
Signature of ApplicanVConuanor �j Dam
HAZARDOUS MATEIV DISCLOSURE Type of Roof
Will the applicant m fugue willing oaupatsmre m hadk haardav material
as defined by the Cupnino Municipal Cade.Chapter 9.12.and the HaIN and Safety
cook.Smtiw zs532(.)T
❑Yee `J All roofs shall be inspected prior to any roofing material being installed.
5yvsa
Will tw.pplicart or future wilding oa7teont am equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hnaNnmo air contaminants u defend by Jct Bay M.At,Quality Management all new materials for inspection.
nrictT
❑Yes j�Flu
L hate mat the huardous mawrialsmquhcments under Chapter G95 afore Califor.
nia Health&Safety Code.Seen=25505,21533 ad25534.1 undcramW Naifore wading //�/Q'
does not cmwntly haw•mnanL that It u my responsibility me
ibility notify Jct upant of the W ! /
req.' Iswhich mem be awr w issuance of a Certificate of Occupancy. Signature of Applicant Date
s-OF All roof coverings to be Class'1W'or better
Owner err mthamt agcm Dam'
CITY OF CUPERTINO
• 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: pdtg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36626046 . 00
DATE ISSUED. . . . . . . : 11/19/2008
RECEIPT #. . . . . . . . . : BS000006646
REFERENCE ID # . . . : 08110070
SITE ADDRESS . . . . . : 21001 SEVEN SPRING PKWY
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : JOHN MAR
ADDRESS . . . . . . . . . . : 21001 SEVEN SPRING PKWY
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : EDWARD GREGORY
CONTRACTOR . . . . . . . : MCGEE, PAT LIC # 18986
COMPANY WATER HEATERS ONLY
ADDRESS . . . . . . . . . . : 970 E MAIN ST
CITY/STATE/ZIP . . . : GRASS VALLEY, CA 95945
TELEPHONE . . . . . . . . : (800) 835-5946
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- - - ---------- ----------
1BSEISMICR VALUATION 975 . 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
CITY OF CUPERTINO
ZVI WATER HEATER
•CUPERTINO PERMIT APPLICATION FORM
eller
APN # Date:
Z
Building Address:
2 loo / Se✓e-i Sllori'-,ys T11rwY1
Owner's Name: . Phone #:
—T-o ,t yob- 99G - 9Z z 8
Contractor: Phone #:sa0- Z 7Y- 3,TV/
Fax #:
Cupertino Business License #: Contractor State License #:
,;2 9/oo 3 7y ,573
Contact: 5d 6re� Phone #:mea- (,zv
W,raH; Fax #: SYv-yd'Y-b'doq
Building Permit Info:
Bldg Elect Plumb Mech
Residential Commercial ❑
Job Description:
Strapped On Platform Bonded New Location ❑ Replacement
Valuation (cost of project):
Project Size: Express LLJI 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 Buildin Points achieved:
Revised 6/16/08
CITY OF CUPERTINO
Sim-, WATER HEATERCITY OF
�
CUPERTINO . PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCWHEATR Commercial Water B PCWHEATR
HeaterNent
1BSEISMICOM Seismic Commercial B
1PRWHEATR Residential Water B PRWHEATR
HeaterNent
1BSEISMICRE Seismic Residential B
/ 1 PPERMITFEE Plumbing Permit P
I •
ITRAVDOC Travel & B
Documentation
1BUSLIC Business License B