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07030295 CITY OF CUPERTINO BUILDING DIVISION PERMIT NT Gds I ` ?RMr4TI€3N PERMIT NO. BUILDING ADDRESS: 6685 CLIFFORD DR ALL VALLEY PLUMBING 07030295 PERMIT ISSUE DATE ^WNER'S NAME: GILL WILBUR J TRUSTEE & ET AL 3345 SELDON CT 3/27/2007 SANITARY NO. CONTROL NO. PHONE: BUILDING PERMIT INFO ARCHITECT/ENGINEER: WATER HEATER REPLACEMENT BLDG ELECT PLUMB MECH 0 0 o a 100 LICENSED CONTRACTOR'S DECLARATION Job Description Lu I hereby affirm that I am licensed under provisions of Chapter 9(commencing z with Section 7000)of Division 3 of Ute Business and Professions Code,and my license is yin full force and elf} $ p t vM z License CI 3 ►to• F, Date ? Conuactor a ARCHITECTS DECLARATION I derstand my pl s shalMle used as public records )Lu U U.in Licensed tfcssionat a OWNER-BUILDER DECLARATION t}� 1 hereby affirm that I am exempt from the Contractor's License Law for the jp o following reason.(Section 7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure n prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation -?a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 >q.Ft.Floor Area t= (commencing with Scction 7000)of Division 3 of thc Business and Professions Code)or e. L ., that he is exempt therefrom and the basis for the alleged exemption Any violation of Section 7031.5 by arry applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not more than five hundred dollars($500). ❑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 'Required Inspections and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale.If, however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li- ccnse Law does not apply to an owner of property who builds or improves thereon,and. who contracts for such projects with a contractor(s)licensed pursuant to the Contractors License Law. ❑I am exempt under Sec. B&P C for this reason miner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑I Itsve and will maintain a Certificate of Consent to self-insure for Worker'sCompen- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number are: Cartier:"1"NE ZL}i111i PolicyNo.: C 0(033-J O I CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Chis section need not be completed if the permit is for one hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued.1 shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Workers Compensation provisions of the Labor Code,you must ,J. O forthwith comply with such provisions or this permit shall be deemed revoked. Z, CONSTRUCTION LENDING AGENCY [~o C4 1 hereby affirm that there is a constructinn lending agency for the performance of (Z> the work for which this permit is issued(Sec.3097,Civ.C.) W A Lender's Name aLender's Address U O 1 certify that I have read this application and state that the above information is H Correct.I agree to comply with all city and county ordinances and state laws relating to rJ U building construction,and hereby authorize representatives of this city to enter upon the W ahovc-mentioned property for inspection purposes. 4+ (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs and expenses which may in any way accrue against said City y� U Z in consequence of the granting of this permit. Date APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SOUR REGULATIONSA. . Q, 1/2,_710-7- Re-roofs Signature ofApplican Contractor Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety 'ldc,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes / If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes No I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building docs not currently have a tenant,that it is my responsibility to notify the occupant of the require rats which must be met prior to is,trance of a Certificate of Occupancy. Signature of Applicant Date , LAL,_ ' .5J�7 All roof coverings to be Class"B" or better Owner or authorized agent Da CITY OF CUPERTINO 3 ITEMS OF 6 PERMIT RECEIPT OPERATOR: christya COPY # 1 Sec: Twp: Rng: Sub: Blh: Lot: APN . . . . . . . . . 361,26014. 00 DATE ISSUED.. . . . . . . : 03,'27/2007 RECEIPT #. . . . . . . . . : BS000000804 REFERENCE ID # . . . : 07030295 SITE ADDRESS 6685 CLIFFORD DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . : OWNER GI:,L WILBUR J TRUSTEE & ET AL ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : CU:?ERTINO CA, 95014-4530 RECEIVED FROM . . . . : RECEIPT INTERFACE CONTRACTOR MAZY SANDBRINK LIC # 23015 COMPANY . . . . . . . . . . : AL:j VALLEY PLUMBING ADDRESS 3315 SELDON CT CITY/STATE/ZIP . . . : FREMONT, CA 94539 TELEPHONE . . . . . . . . : (510) 376-4816 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---- BENERGY PERMIT FEE 1. 00 34 . 86 0. 00 34 . 86 0 .00 BPWHEATER PER HEATER 1. 00 10.79 0 .00 10.79 0. 00 PPERMITFEE FLAT RATE 1. 00 38.37 0. 00 38.37 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 84 . 02 0. 00 84 . 02 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 168. 04 7865 --------------- TOTAL RECEIPT 168 . 04 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------- 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE CITY OF CUPERTINO PERMIr.i INVOICE OPERATOR: christya Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . . 36926014. 00 INVOICE DATE. . . . . . : 03.127/2007 REFERENCE ID # . . . : 07030295 SITE ADDRESS . . . . . : 66:35 CLIFFORD DR SUBDIVISION . . . . . . : CITY . . . . . . . . . . . . . . CU?ERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . . GI.�L WILBUR J TRUSTEE & ET AL ADDRESS . . . . . . . . . . . CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4530 CONTRACTOR MA3,Y SANDBRINK LIC # 23015 COMPANY ALS VALLEY PLUMBING ADDRESS 3315 SELDON CT CITY/STATE/ZIP . . . : FREMONT, CA 94539 TELEPHONE (510) 376-4816 FEE DESCRIPTION DUE FOR AMOUNT DUE PAID BALANCE --------------------------- ---------------- ---------- ---------- ---------- ENERGY APPLICATION 34. 86 0. 00 34 . 86 WATER HEATER/VENT PRINTING PERMIT 10.79 0 . 00 10.79 PLUMBNG PERMIT ISSUE PRINTING PERMIT 38. 37 0. 00 38 .37 ---------- ---------- ---------- 84. 02 0. 00 84 . 02 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------- - 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING CITY OF CUPERTINO V-7 WATER HEATER CUPEkTINO PERMIT APPLICATION FORM APN# ` Date: \ Building Address: �� ► arc'( r Owner's Name: Phone#: Ol s 1 L 1 -`�� I Contractor: P iez License#: Ina elle Contact- or.� Cupertino Busm License#: �� r�n Building Permit o: i Bldg ❑ Elect C9-- PIumb Meeh Job Description_ Residential Commercial ❑ i r Cost of Project Strapped On flatform Bonded New Location i Replacement Qty-if Applicable Fee ID Fee Description Fee Group BITER Water Heater 1 Vent BUILDING PPlER*ffrFEE Plumbing Permit Issuance PLUMBING B GY Energy BUILDING BMJC Business License BUILDING R