07030173 CITY OF CUPERTIIVO nT�y '(�p
BUILDING DIVISION PERMIT C�11Tt� TO
if\ � 3r� �l��e
PERMIT NO.
BUILDING ADDRESS:
10082 MOSSY OAK CT WATER :EATERS ONLY 07030173
PERMIT ISSUE DATE
OWNER'S NAME:
EMERICH ROBERT AND BARBARA ET 970 E. MAIN STSUITE 200 03/22/2007
SANITARY NO. CONTROL NO.
ONE:
I
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: REPLACE WATER HEATER BLDG ELECT PLUMB MECH
C7 D D O
o? LICENSED CONTRACTOR'S DECLARATION Job Description
m� I hereby affirm that I am licensed under provisions of Chapter 9(commencing
:U1
with Section 7000)of Division 3 of the Business and Professions my license is
N in full force and effect C
? Licensc CI s b Lic.k 3 77 s
Contractor
p
F Dam A CTECTS HIDECLA 10
J
j x< I understand my plans shall be used as public records
)qU
u.l- Licensed Professional
: a OWNER-BUILDER DECLARATION
aI hereby affirm that 1 am exempt from the Contractors License Law for the
z a 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
s" prior to its issuance,also requires the applicant Cor such permit to file a signed statement Valuation
SFt.Floor Area
-?a that he is licensed pursuant to the provisions of the Contracmr s License Law(Chapter 9 q
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i 3 that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number
not more than five hundred dollars(5500).
0 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.70",Business "Required Inspections
and Professions Code:The Contractors License Law dots 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.).
0 I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contrxor's Li-
cense 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 Contractor's
License Law.
0 I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consent to self-insure for Workers Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance oC the
work for which this permit is issued.
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 Com ensati 1 u c carrier and Policy number are: ,.aa��}r
Cartier. f 1 Policy No.: 7c-0 J~V`
CER111FICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This 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.I 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 Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z OCONSTRUCTION LENDING AGENCY
rCA
- I hereby affirm that there is a construction lending agency for the performance of
(� the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lenders Name
2 z Lender's Address
I certify that 1 have read this application and state that the above information is
O correct.1 agree to comply with all city and county ordinances and state laws relating to
V Vbuilding construction,and hereby authorize representatives of this city to enter upon the
W ahovc-mentioned property for inspection purposes.
G7, (We)agree to save,indemnify and keep harmless the City of Cupertino against
H rA liabilities,judgments•costs and expenses which may in any way accrue against said City '7
U Z in consequence of the granting of this permit. Date f� L�
►-� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b.i:
SOURCE REGULATIONS.
Re-roof:
Signature of Applicant/Conuactor Date T of Roof
MATERIALS DISCLOSURE Type
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
Code,Section 25532(a)? All roof;shall be inspected prior to any roofing material being installed.
0Yes P�Ne 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,naterials for inspection.
District?
0 Y. 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 nily have a tenant,that it is my responsibility to notify the occupant of the
require hick must met pri issuance of a Certificate of Occupancy._ Signatui a of Applicant Date
>"Zz" All roof coverings to be Class"B"or better
Owner or authorized t Date
CITY OF CUPERTINO
3 ITEMS OF 6 PERMIP RECEIPT OPERATOR: bethe
COPY # 1
Sec: Twp: Rng: Sub: Blc: Lot:
APN 34232112 . 00
DATE ISSUED. . . . . . . : 03/22/2007
RECEIPT #. . . . . . . . . BS000000753
REFERENCE ID # . . . 07030173
SITE ADDRESS 10082 MOSSY OAK CT
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : EMERICH ROBERT AND BARBARA ET
ADDRESS . . . . . . . . . . .
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5615
RECEIVED FROM . . . . : RECEIPT INTERFACE
CONTRACTOR . . . . . . . : MCGEE, PAT LIC # 18986
COMPANY . . . . . . . . . . : WATER HEATERS ONLY
ADDRESS . . . . . . . . . . : 970 E. MAIN ST, SUITE 200
CITY/STATE/ZIP . . . : GRASS VALLEY, CA 95945
TELEPHONE . . . . . . . . : (800) 835-5946
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
----------------- --------------- --------------------
CREDIT CARD 168 . 04 MASTERCARD
---------------
TOTAL RECEIPT 168 .04
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
CITY OF CUPERTINO
ismWATER HEATER
OF
CUPEkTiNO PERMIT APPLICATION FORM
p�o�Dl73
APN# Date: 3 — ZZ-07
Building Address: 0 82 y )o s3 Oct 4 0 7—
Phone
Owner's Name: / — ,
S. 3j �/ 4 � !C �
Contractor: Phony;: License#:
C), boy- zsT- Y313 37`/S-173
Contact: Phone.: Cupertino]Business
License#:
Edward- Gregory one: IS 7 /Z�� `b
Building Permit Info:
Bld ❑ Elect ❑' Plumb Mech
Job Description: . /� � / / �
zleaka
Residential Commercial ❑
Cost of Project: `n
Strapped O�Plat�form
❑ Bonded
New Location ❑ Re lacement
Qty. if
A licable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPEgMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
Community Development
- - 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
f,-,UPE(�TIN0
Buildin De artment
JOB ADDRESS: l CIO /�v s 5-,l04 Gr ; PERMIT# O 1 �
1 f'uz� v�? 3 O l
OWNER'S NAME:�`'n�/ �,�,,e r rc(� /-ted ! L PHONE #Vo8_a 3!3 Yv ZS Z 8 �
GENERAL CONTRACTOR: FAX#
I am not using any subcontractors: 3 --1`0
Si gnature 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
Date
Owner/Contractor a
i