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07030171 CITY OF CUPERTINO BUILDING DIVISIONPERMITiTG'�'C�R It�RMAT €IN•. BUILDING ADDRESS: PERMIT NO. 10591 STOKES AV WATER H ATERS ONLY 07030171 OWNER'S NAME: PERMIT ISSUE DATE TIERNEY FREDERICK W 970 E. MAIN ST I 7 INE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO REPLACE WATER HEATER BLDG ELECT POLUMB MECH 0 D D �o p LICENSED CONTRACTOR'S DECLARATION v" I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description awith Section 7000)of Division 3 of the Business and Professions Code,and my license is n in full force and effectC : ? License Class \•J fo Lic.N t p DatcC�7 Contractor ARCHITECTS DECLARATION g U I understand my plans shall be used as public records ,a y Licensed Professional r OWNER-BUILDER DECLARATION j<n 1 hereby affirm that I am exempt from the Contractor's License Law for the :MO following reason.(Section 7031.5,Business and Professions Code:Any city or county �i which requires a permit to construct,alter,improve,demolish,or repair any structure Z y prior to its issuance,also requires the applicant Cor such permit to file a signed statement _ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sc.Ft. Floor Area Valuation t— (commencing with Section 7000)of Division 3 of the Business and Professions Code)or L .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of araC APN Number OCCU not more than five hundred dollars($500), Occupancy Type ❑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 and Professions Code:The Contractor's License Law docs not apply to an owner of "Required Inspections 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.). ❑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 Li- cense Law does not apply to an owner of property who Milds or improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. ❑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: L]I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- 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 Worker's 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 Cor nsatiq In{�v�rayce carrier and Polity number are: (I Carries - / /PolityNo.:� V '0/1 CERTIFICATE OF EXEMPTION FROM CERS' 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 Oforthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY -+�r I hereby affirm that there is a construction lending agency for the performance of li> the work for which this permit is issued(Sec.3097,Civ.C.) QLender's Name z Lender's Address J Q I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to J J building construction,and hereby authorize representatives of this city to enter upon the / CIa above-mentioned property for inspection purposes. y a (We)agree to save,indemnify and keep harmless the City of Cupertino against \\ ti co) liabilities,judgments,costs and expenses which may in any way accrue against said City Z in consequence of the granting of this permit 'r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date [— SOURCE R G ATIONS. I AItLA-P 3`2 `t�� Re-roofs Signature of Applicant/Contractor 4V U Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant storeor handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the Health and Safety Code,Section 25532(a)? All roofs sha;1 be inspected prior to any roofing material being installed. ❑Yes �t o Will the applicant or future building occupant use equipment or devices which If a roof is in italled without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new matef ials for inspection. District? ❑Yes Ir. 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 requiremen w ' must be met p, r to i mf a Certificate of occupancy. Signature of f.ppl ieant Date All roof coverings to be Class"B"or better Owner or authorized gcn Date CITY OF CUPERTINO 3 ITEMS OF 6 PERMIT RECEIPT OPERATOR: bethe COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32649022 . 00 DATE ISSUED. . . . . . . : 03/22/2007 RECEIPT #. . . . . . . . . : BS000000753 REFERENCE ID # . . . 07030171 SITE ADDRESS . . . . . : 10591 STOKES AV SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER TIERNEY FREDERICK W ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1239 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 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ----------------------------- -------- ---------------------------- 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING CITY OF CUPERTINO WATER HEATER CUPEI�TINO PERMIT APPLICATION FORM 0103011,71 APN# 3,2�P ,. 4q -0�� Dater-- Z Z - p;�;, Building Address: n S 9/ S 7,1--o `e s / v& Owner's Name: Phone#: i erre x/000 2 's,2- Contractor: Phone. License#: 375/,S-7-3 �c-Ver Ale 61 J, (��, �. c 5,-",0- '17(-1-3r�� l Contact: Phone: Cupertino Business License#: Edward Gre ory 2 S- Building Permit Bldg ❑ Elect Plumb ,� Mech Job Description: %, - Residential Commercial ❑ Cost of Project: YUO Strapped On Platform ®-'- Bonded'a INew Location ❑ Replacement Qty. if Applicable Fee ID Fee Description Fee Group BPWHEATER Water Heater/Vent BUILDING PPERMITFEE Plumbing Permit Issuance PLUMBING BENERGY Energy BUILDING BUSLIC Business License BUILDING