08120048 CITY OF CUPERTINO n-
BUILDING DIVISION PERNUT 1NR St 9
BUILDING ADDRESS: PERMff NO.
22018 MC CLELLAN RD HOME DEPOT
OWNER'S NAME: PERMrr ISSUE DATE
O SA CONTROL NO.
ARCHI ECTAiNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
RMV/RPLC GAS WATER HTR O O O D
u0o LICENSED CONTRACTOR'S DECLARATION
U I is mby affirm mat 1 am licensed under provisions or Chapter 9(commencing Job Description
with Section 70M)of Division Sof the Business and Professions Code.and my license I.
in full forte and cffm,
j Z License Clea Le.Y
Dam Cottonton,
ARCHITECTS DECLARATION
W iJ 1 unM.manJ my plans snail be asW a public mrords
gG Leotwd Pmresvonal
c 5 OWNER-BUILDER DECLARATION
I hcroby aRrm Thal 1 am exempt from the Conueaoes License Law for the
no folbwing reason.(Section 7031.5,Bum.and Profeitiva Code:Ary city m only
I
$ which mquima a permit w construct a@n,imptow,demolish,m repair any su ecum,
°zt prior no its issuance.also requires de applicant for such Permit w file a signed statement
that he is licensed parwantwthe provisions of we ConuacwYs Liaoe Law(Chapter 9 Sq.Ft.Floor Area Valuation
X52 (commencing wide Section 70MB of Division 3 of the Bea..and Pmfsumns Code)ar
that he is exempt mconfmm and the basis for the alleged exemption Any violadon of
Send.7031.5 by airy applicant far•permit subjects me apple.,to a civil penalty of APN Number Occupancy.1 mom m.five hundred dollars($500). P y TYPe
❑I,a owner of de property,m my emplayw with wages as de's Som cnmpevadon,
wits do mesionk..dthe he ContranotkteMW Law do nortale(Sec.]0at.,Bassir of
and enyw1dorts Calc The ConacmYs w•«law dna ret appy w..war o< Required Inspections
propertyIOM dui Idsmireprowschueon.andamus does auntwank A md elfmthree
wn ads rt
oemployees,provided such en impmwmes raw,
utie ,intended araQeIre ale.If.
however.the building ar improvementm is sold within ayear of completion the owner.
ban0
der wllute de burden of proWhe
provide that did not Wild or Improve for purpose of
ask.).
Q 1.u arm of the property ma excilusivaiy contracting with licensed conmous or
consorct the project(Sec.7044.Business and Pmfecdons Cade:)The Conuacmr's U.
mac law dans am appy to an owner of property who Wilds or improves t erecn.and.
who contracts for such projects with a conwc,o(s)licensed pursuant to the Commoner
License raw.
❑lamexemptundu See ,B&PCfm Nireemon
Owner Date
WORKER'S COMPENSATION DECLARATION
1 thereby a fluor under penalty or pujury,one of de fallowing dtnda motto
I ham and will maintain a Ceruficam of Consent w self-homm for,Yorkers Comped.
tion,a provided for by Section 3700 or the Labor Code.for Ne peRormance of the
wok for which this permit is island.
❑1 have and will maintain Worker's Compensation Insurance,as required by Second
3700 of Ne Labor Code,fm me,performamx of de works for which this permit is issued. '
My Worker's Compensation Insurance eerier and Policy number am:
Cartier. Policy No,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ITuaec ica need an,he completed time Permit Isforone hundred dollars(SIMI
or bees)
I cenify that k the Mr..of the work for which mu Permit is toad.I shall nm
employ my person is my mare¢,se as to become wbjec,or the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT.If,after mating this Cenificate of Exemption,you should
become subject m the Worker's Compedeaunn provisions of me iabm Code,you must
.JO forthwith comply with such provisions or mu Permit shall be decmW towhead.
Z 7) CONSTRUCTION LENDING AGENCY
[—t rte. I hereby affirm most mem is a construction lending agency for the Performance of
CL the work for which this Permit is bound(Sec.3097,Civ.C.)
Q Iander's Name
0, AddressAddressz Lender's Add
U O 1 certify that 1 haw mad this application and tum this the above iNnrmadan is _
corm.,I agrce w comply with W city and county ordin.cea and state laws relating w
.� building construction,and hewhy aummim rePnuenuuws of this city to ante upon the
.bow-mwdoned Property for inspection purposes.
(We)ag=to ate,indemnify and kap hanmlaa the City of Cupertino against
rq imbili0es,judgments.costs and expenses which may in my way wcme against aid City
U Z in cosami once of the Swung of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
SiSignatureof ApplkaO Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII y t applicant or future Wilding n.Chapter
or Mddk h eallous material
u nn.Sec by the Cupertino Municipal Cade.Chep¢,9.13.and the Health.d Safety
emk.Section 155324)t
❑Yes ON. All roofs shall be inspected prior to any roofing material being installed.
Will do applicant or future Wilding occupant tie cquipmcrn or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t haandnus air cottumim us as defined by me Bay Arta Air Quality Management all new materials for inspection.
strict
❑Yns ON.
I haw read In harallousen eriab iequire.rtu ureic,Clupmr6.95 of me cafirm.
nu HnslN&.SaiuyCadc,Scctieu255u5.255J1 an125534.1 umkmaM thmifde Wilding
does no currently have a tenant.that it a my responsibility w mufy the occupant of the
requirements which most be met prior m Women of a Certificate of Occupancy.
Signature of Applicant Date
Owner or athonred agent Daw All roof coverings to be Class'1W'or better
CITY OF CUPERTINO
• 4 ITEMS OF 24 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . . 35608038. 00
DATE ISSUED. . . . . . . : 12/04/2008
RECEIPT #. . . . . . . . . : BS000006763
REFERENCE ID # . . . : 08120048
SITE ADDRESS . . . . . : 22018 MC CLELLAN RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : KOPA, DAVID
ADDRESS . . . . . . . . . . : 22018 MC CLELLAN RD
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4060
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
a
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
•CUPEkTINO
Building Department
JOB ADDRESS: 22018 MCCLELLAN RD PERMIT#
os/off o C)
OWNER'S NAME: KOPA,DAVID PHONE# (408)873-8989
GENERAL CONTRACTOR:HOME DEPOT FAX# 425-814-9516
I am not using any subcontractors: �Z`OF,%."&-ap 1114108
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
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
• Owner/Contractor Signature Date
O9/� (Y)
(office
•
Permit No: 7
(office use only)
City Of Cupertino Building Permit Application
E-Mail: Building-Permits(cDcupertino.org (Address is case sensitive).
Jobsfte Address:22018 MCCLELLAN RD Date: 11/4/08
Assessor's Parcel Number: 35600 f D .
Owners Name: KOPA,DAVID Phone No: (408)873-8989
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: 9/30/10
Worker's Comp No: 1928756 Expiration Date: 3/1105
Carrier: AMERICAN HOME ASSURA
City of Cupertino Business License No: 'PrPok eco
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
contractorlsubcontractor form need to be submitted with each permit.