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07050011 CITY OF CUPERTINO BUILDING DIVISION PERMIT co GTQR p:,.._�4TI43�� BUfL13ItQ¢I�BES$� MIT NO. WALNUT CL PLUMB N TIME INC PER 07050011 OWNER'S NAME: N PERMIT ISSUE DATE LEE, DO 360 MEMORIAL DR STE 140 05/01/2007 NE: SANITARY NO. CONTROL NO. ARCHITECT/ENG(NEER: BUILDING PERMIT INFO REPLACE, WATER HEATER BLDG ELECT PLUMB MECH i p p LICENSED CONTRACTOR'S DECLARATION Job Description U p 1 hereby affirm that I am licensed under provisions of Chapter 9(co Pricing z with Section 7000)of Division 3 the Business and Professions C license is t<a in full force and effect a�v j ? License C Lic.8 Date — Contractor RCHrrECI'S DECLAIRATAq 7 C 1 understand my plans shall be used as public records )yU a l Licensed Professional y OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the p O following reason.(Section 7031.5,Business and Professions Code:Any city or county u which requires a permit to construct,alter,improve,demolish,or repair any structure prior to its issuance,also requires the applicant for such permit to file a signed statement r' ,Ft.Floor Area Valuation -?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 •tq ,4 F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or it that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type 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.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 We.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 Contractor'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 conuactor(s)licensed pursuant to the Contractor's License Law. 0 I am exempt under Sec B&P C for this reason Owner Dare WORKERS 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 Workces Compen- sation,as provided for by Section 3700 of the Labor Code,for the performance of the woor which this permit is issued. I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of�co. ns dfh pe orrmt of the work for which this permit's issued. My Wotcc ca 'er aannd li nu `Carief0 MPTION FROMWORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for anc hundred dollars($100) or less.) I cenify 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.Dale 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. z" CONSTRUCTION LENDING AGENCY Fr rA 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.) QLender's Name 2 Lender's Address U 0 I certify that 1 have read this application and state that the above information is w►� correct.I agree to comply with all city and county ordinances and stale laws relating to Vbuilding construction,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes. a (We)agree to save,indemnify and keep harmless the City of Cupertino against "t/) liabilities,judgments,costs and expenses which may in any way accrue against said City U 2 in consequence of the grpdng of this permit. Date UNDERSTANDS WILL COMPLY WITH ALL NON-POI Issued by:!�WPLICA GULATI,C�(S. lam- Re-roofs tgnatrill f Applicant/Con or Dare Type of R sof HAZARDOUS MATERIALS DIS Lof the applicant or future building occupants or handle hazardous material as defined by the Cupertino Municipal Code.Chapter .12,and the Health and Safety Code,Section 25532(a)? All roofs:;hall be inspected prior to any roofing material being installed. 0 Yes o Will the applicant o future building occupant use equipment or devices which If a roof i:;installed without first obtaining an inspection,I agree to remove Will the applicant oZuu.building occupant use equipment or devices which emit hazardous air contaminants fined by the Bay Area Air Quality Management all new m 3terials for inspection. District? 0 Yes No I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the building docs not c have a tenant,that' my responsibility to notify the occupant M the ich mast l p r i trance of a Certific of�Pap Signature of Applicant Date All roof coverings to be Class"B"or better wnc on.ed agent Date CITY OF CU?ERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: bethe COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35703064 . 00 DATE ISSUED. . . . . . . : 05/01/2007 RECEIPT #. . . . . . • • • : BSO00001171 REFERENCE ID # . . . : 0705C0ll SITE ADDRESS . . . . . : 2242 N WALNUT CL SUBDIVISION . . . . . . . CITYCUPERTINO . . . . . . . . . . . . . .• IMPACT AREA . . . . . . . OWNER LEE, DO ADDRESS . 95014 CITY/STATE/ZIP . . . : CUPERTINO CA, RECEIVED FROM RECEPAULCPT HENDRIXSONCE LIC # 27607 CONTRACTOR . . . . . . . COMPANY . . . . . . . . . . : PLUM3 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 . -- -----38_37 ------ -- ----- ------- ---------- TOTAL PERMIT : 84 . 02 0 .00 84 .02 0 . 00 METHOD OF PAYMENT AMOUNT --REFERENCE NUMBER ----------------- --------------- -- CHECK 84 . 02 50373 --------------- TOTAL RECEIPT 84 . 02 VOICE ID DESCRIPTION VOICE- -------- ID DESCRIPTION --- -- ------------------ --------- ----- -- ----------- 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING CITY OF CUPERTINO WATER HEATER CUPE T NO PERMIT APPLICATION FORM 0,5601 APN# Date. Building A ;1dress- w* Owner's Name: Phone#: 0 1,.CG Ll o$- b91- a S A Contractor: License#: W 0161 Contact: Cupertino Business License #: Building Permit Info: Bldg ❑ Elect E�— Plumb Mech �1 Job Description: Q C Li4jr en Ll Residential Q' Commercial ❑ Cost of Project:ICU. Strapped On Platform Bonded New Location ❑ Replacement Qty. if Applicable Fee ID Fee Description Fee Group BPWHEATER Water Heater/Vent BUILDING PPERMITFEE Plumbing Permit Issuance PLUMBING BEN ERGY Energy BUILDING BUSLIC Business License BUILDING Community Development 10300 Torre Avenue is Cupertino CA 95014 Telephone(408)777-3228 CIV OF Fax(408)777-3333 'TPEkTIN0 Building Department JOB ADDRESS: y�9 5- bt� �/ r PERMIT # cooly 1 OWNER'S NAME: PHONE GENERAL CONTRACTOR: ` FAX # I am not using any subcontractor Sinnature Date Please check applicable subcontractors and corn ►lete 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 �.. �- 0 '-Owner/Contractor Signatr Date