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07030144 CITY OF CUPERTINO �, �.� R Zji ][ TQ BUILDING DIVISION PERMIT PERMIT NO. BUILDING AgDRESS: pLjJlvjg I V TIME INC 07030144 116y7 PALM SPRING CT PERMIT ISSUE DATE OWNER'S NAME: HSU, BEN 360 MEMORIAL DR STE 140 03/20/2007 SANITARY NO. CONTROL NO. ,ONE: BUILDING PERMIT INFO ARCHITECT/ENGINEER: REPLACE WATER HEATER BLDG ELECT PLUMB MECH ed a LICENSED CONTRACTOR'S DECLARATION Job Description vI hereby affirm that I am licensed under provisions of Chapter 9(commencing U w with Section 7000)of Division o the Business and P Code,and my license i 2<= in full Cone and effec v�z License Contractor LIC. Contractor U3 Dale R ITECTS DECLARAT N j a< I understand my plans shall he used as public records >0.0 U.y Licensed Professional a OWNER from DECLARATION I hereby alfrm that I am exempt from the Contractor's License Law for c p Or� following mason.(Section 7031.5,Business and Professions Codc:Any city or county which requires a permit to construct,alter,improve,demolish,or repair ed structure -fin prior to its issuance,also requires the applicant for such permit to file a signed statement ; .Ft.Floor Area Valuation -Z a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or Y that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500). 1,as owner of the property,or my employees with wages as their sole compensation, Required Inspections will do the work,and the structure is not intended or offered for sale(Sec.7044,Business and Professions Code:The Contractors 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 employes,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.). I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's U- of property who builds or improves reon,and. who contractLaw does Cor such pnot ly to an rojects with arc contractor(s)licensed pursuant to the Contractor's License Law. B&P C for this reason C3 am exempt under Sea Owner Date WORKER'S COMN PENSATION DECLARATIO 1 hereby affirm under penalty of perjury one of the following declarations: a1 have and will maintain a Ccrtifrato of Consent to self-insure for Workers Compen- ion,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. C]I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of theaor Ctmy ckf yb ici �t is issued. h My Win CmnIe G@nsu Carrier olity No.: CE FICATE OF EXEMPTION FROM ORKERS' COMPENSATION INSURANCE (This section need not le 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 ,J ,Z forthwith comply with such provisions or this permit shall be deemed revoked. Z CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of a> the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lender's Name az Lender's Address I certify that 1 have read this application and shale that the above information is U- correct.1 agree to comply with all city and county ordinances and state laws relating to w Jbuilding construction,and hereby authorize representatives of this city to enter upon the above-menuoned Property for inspccuon Purposes. a (We)agree to save,indemnify and keep harmless the City of Cupertino against rA liabilities,judgments,costs and expenses which may in any way accrue against said City _ 7 U Zin consequence of the grating of 's permit. Date APPLI NT UNDERSTAN D WILL COMPLY WITH ALL NON-POINT Issued b U LA NS. Re-roof: ign o Applicant/Contractor Date Type of Roof HAZARDOUS MATERIALS DI LO yP Will the applicant or future building occupant s r handle hazardous material as defined by the Cupertino Municipal Code.Chap 9.12,and the Health and Safety Code,Section 25532(a)? All roof;shall be inspected prior to any roofing material being installed. 0 Y� No If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant future building occu nt u equipment or devices which emit hazardous air con inane as defined by the rea Air Quality Management all new Tlaterials for inspection. District? ❑Ycs .f�No 1 have read the hazarrddou's'materials requirements under Chapter 6.95 of the Califor- Icia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building not currently have a tenant, it is my responsibility to notify the occupant of the Date circ is w h mtu m r w issuance o Ccrtificatc oC cupanry. S ignatw e of Applicant All roof coverings to be Class"B"or better wn r uthorized agent Dare CITY OF CUPERTINO 3 ITEMS OF 3 PERMI" RECEIPT OPERATOR: bethe COPY # 1 Sec: Twp: Rng: Sub: B1]>: Lot: APN 36,354110. 00 DATE ISSUED. . . . . . . : 03 /20/2007 RECEIPT #. . . . . . . . . BS )00000730 REFERENCE ID # 07 )30144 SITE ADDRESS 11597 PALM SPRING CT SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER HS J, BEN ADDRESS . . . . . . . . . . . CITY/STATE/ZIP . . . : BELMONT CA, 94002 RECEIVED FROM . . . . : RECEIPT INTERFACE CONTRACTOR . . . . . . . : PAUL HENDRIXSON LIC # 27607 COMPANY . . . . . . . . . . : PLUMB IN TIME INC ADDRESS . . . . . . . . . . : 360 MEMORIAL DR STE 140 CITY/STATE/ZIP . . . : CRYSTAL LAKE, IL 60014 TELEPHONE . . . . . . . . : (866) 293-3031 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 84 .02 2545 --------------- TOTAL RECEIPT 84 .02 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ------ 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING CITY OF CUpF CU*11­1 WAT-ER R- EATER kTINO PE IT AF-Pj;1�`AT10-rd' FO ply - 070. 0144 uiidIII g f4ddress: --- ;date: a I a 2 1169? CPcxL�nn Sic h 6 (A wnei-'s 1V'ame: ; + i 3 Phone : i Canir c-or: �Iog ggg ' s aas Conta6t: _ 1 icense#: Ruildi, Cupertino Business License g.pernlit info: 81da Job DascrElect [ Pl . iption: irnb Mech i S Resid ' � •-. antiaf - Cornrnercial G d oA S J Cost Of Project: Strapperi ©11 Platform Bonded 1 New ew I-oCation 0— Replacement if- nppli6ble Fee ID P WDescription _ --- PPERMJTFEE Water Heater/'gent Fee Group BEN)-- Pl:�±n Ding Permit Issuance BUILDING BIISI.IC Eneri,y PLU1V{EIN C Busiress License, BUILDMIG B UIL,I)MG ' 1 O C'&al t 4i� IL � .-03 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 ''UPEkTINO Buildin De arr. JOB ADDRESS: > q. SQ h� PERMIT # 3 y "l // 0 70 OWNER'S NAME: PHONE # q0 GENERAL CONTRACTOR: - - # I am not using any subcontractors: -4 — Si';nature Date Please check applicable subcontractors and complete the followinginformation: jZI 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