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08120047BUILDING DIVISION PERAUT BUIIDINGADDRESS: -' I.." rtes 22450 MC CLELLAN RD HOME DEPOT ng12no47' OWNER'S NAME: PERMIT ISSUE DAM . SA CONTROL NO. ARCHRECIYENGINEER: BUILDING PERMIT INFO RMV/RPLC GAS WATER HTR BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description 1 thereby alarm Wt 1 me licamul under Provide" of Chapter (commencing with Section 7") of Divition 3 of the Business mad Protections Cade. aal my licence is in full forte arm effect. Lt.. Chis Lie.0 Dam Comrrosnr ARCHITECT'S DECLARATION 1 undcntand my plans shill be used u Public records Licensed Pmfeasional OWNER -BUILDER DECLARATION T hemby affirm Nat 1 am exempt from the Conu a o's License Law for me following mason. (Section 7031.5. Business and Pmtmtions Cade: My city or county which mqutres a Permit m conswcl- alcor. thapeave, demolish, or repair my sWcmre prior to Its iOvanee. ales nya1T3 dC appliemt for Such permit m lik a Signal sa mmmt Ft. Floor Area Valuation that he;licrosed pursuant to the provisions of the Conaacmrs License Law (Chapter 9 Sq. (commencing with Ueda. 7000) of Division 3 of the Beat. and Profusions Cade) or - thu he u exempt damou rma and the bas; far me allegal exemption Any violation of APN Number Occupancy Type Section 7031.3 by any applicant for a permit subjecu die applicant m a civil penalty N on, mom man five hundred dollars (SSO%. ❑ 1.uownerafinepmpmy.mmyemplo wimwageaudeirmlecompensadon, Required Inspections will do r, andted swctum;nrotinmeded Basorof La.ddforsale(Sec.an an and ons Cade: The Conmcm Uallo law dace col apply lf rt awms tests. property wh other n. who M1Whal(mthis pmpertYwho Wildsoed prove me not intended semugh 11. o employees,provided that such improvements are not intended aroRetod fermate B. that ha the moves, builder, the building o emml; hath within ore year of impove fo. builder will have Ute WNen o! proving that W did rat build or improve for purpose of nden of tale.). ❑ 1. as owner of the Property, am eaclusively contracting with licensed contrclor to construct the project (Sec. 7044. Business and Profeasions Codd:) The Contrncmrs U. corm Law does aot appy an an owrrr of property who Wilds or improves them et. and, who comment for such pmjema with a corma ctor(s) licensed pursuant ne me L'omommrs License Law. ❑ l me remain under See .B d: PC res Out, mamn Oww Dam WORKERS COMPENSATION DECLARATION I hereby affirm under penalty of perjury arm of the following declarations: tram am wi l maintain • Certificate of Connem to self -insure forwarkers Caution, tion, an provided for by Section 3700 of the Labor Code. for me performance of the work for which this permit; earned ' 1 have and will matmesn workers Compensation Insurance, a regmtod by Secure 37/10 of the labor Cade, for the performance of Ne work for which this permit is Issued ' My Worker Compensation hl.. tuner and Policy numbs art: COMPENSATION INSURANCE test W completed Bus: perenit; turn. hundred dollar (510(0 certify that in the performance of ern work for which this Permit ;Wood, I chant not middy my Peron in my summer u m bncome subject m de Worker' Compensation NOTICE TO APPLICANT: IL after milting this Cenifiam of Exemption, you should become subject to me Workers Compensation provisions of me lahor Code, you must .J z forthwith comply wise such Provisions, m this permit shall W doomed rooked. z O CONSTRUCTION LENDING AGENCY [-. 1 hereby affirm that mem; a construction lending agency for the performance of R'i > the wank for whim Nis permit; issued (Sec. 3097. Civ, C.) W� Q Lenders N. 7 z Leaders Adds, U C) I cvtify mat I haw rad that application and sate than me abom information is L, f" correct. I agtoe m comply with all city and county aNinuura and sum laws totaling to _C U Wilding construction, and hereby rolthorlre mpresmutives of Out city an enter upon the r [t7 a ovo-mentioxd property for inspcmian purposes g), (We) agree to save. indemnify and kecp harmless the City of Cupertino against liabilities,judgments, costa road expenses which may lo my way acme, against and City U 7 in consequence of me gnming of this permit. •7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued SOURCE REGULATIONS. Signamre of ApplicanuCanuanar Dam HAZARDOUS MATERfAi3 DISCLOSURE Will the applicant Or future Wilding occupantgwe ar handle havaNau material U defined by dm Cupenlaa Municipal Code. Chapter 9.12. road use Healer and Safely Cade, Section 23332(07 ❑ Yes 0 No Will the applicant or future Wilding ¢cvpant use equipment or devices which bit haneadow air cmaminanu at defrncd by the Bay Area Air Quality Management Yen ❑ No mom@SntlyyCedc, Sections auL iii myresponsibility esu1n530.1 umkrsi, to occupant Wilding not currently Wm a tenant dun it u my rapof. ccu m notary de occupant of dr remcns, whleA meq de met pion to issuance o(a Cvtifram of Occopuuy. Dam Re -roofs Type of Roof Date All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant Date All roof coverings to be Class ern" or better . 4 ITEMS OF 24 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 35604021.00 DATE ISSUED.......: 12/04/2008 RECEIPT #.........: BS000006763 REFERENCE ID # ...: 08120047 SITE ADDRESS .....: 22450 MC CLELLAN RD SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OPERATOR: patg COPY # : 1 OWNER ............: CADA CARL C AND DORIS M TRUSTE ADDRESS ..........: 22450 MCCLELLAN RD CITY/STATE/ZIP ...: CUPERTINO CA, 95014-2753 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 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 518 WATER HEATER E �w •CUPEkTINO • Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 arf-ment JOB ADDRESS: 22450 MCCLELLAN RD PERMIT # vita c)0 y 7 OWNER'S NAME: CADA,CARL PHONE # (408)257-1199 GENERAL CONTRACTOR: HOME DEPOT FAX # 425-814-9515 I am not using any subcontractors: — c2a.ia: e`�.'4eep 11/4/08 Signature Date Please check applicable subcontractors and complete the foilnwinQ;nfnrmnrinn- 0 Owner/ Contractor Signature Date 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 0 Owner/ Contractor Signature Date 0 _ Permit No: 45/o70Oy7 000000 (office use only) City Of Cupertino Building Permit Application E -Mail: Buildinq-Permits(a)cupertino.orq (Address is case sensitive). Jobsite Address: 22450 MCCLELLAN RD Date: 11/4/08 Assessor's Parcel Number: 351oD �/�a/• �� Owners Name: CADA,CARL Phone No: (408)257-1199 Project Valuation: 449.00 Permit Info: Bldg Elect Plumb X Job Description Remove/Replace Gas Water Heater Contractor Information Company Name: HOME DEPOT Contact Name: Carol Randall Address: 12601 132ND AVE NE City, State & zip code: KIRKLAND, WA 98034 State Contractor's Lic. No: 602331 Worker's Comp No: 1928756 Carrier: AMERICAN HOME ASSURA of Cupertino Business License No: Phone No: Fax No: 800-454-8955 E-mail: carolr@fastwaterheater.com Expiration Date: 9/30//0 Expiration Date: 3/1/09 e'k jOlO i O 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.