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06100007BUILDING DIVISION PERMIT BUILDING ADDRESS: 930 BROOKGROVE LA OWNER'S NAME: DYMLING STEN INE: ARCHITECT/ENGINEER: 1 o 0 LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing ? Nwith Section 7000) of Division 3 of the Business and Professions Code, and my license is ? ,a„ in full force and of L(� Qr Z License Class Lic• M 1 ;:,o :w Date 14 1 ! of _ Contractor ,,,t ARCHITECPS DECLARATION W < 1 understand my plans shall be used as public records )yU c n Licensed Professional H OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the 00 following reason. (Section 7031.5, Business and Professions Code: Any city or county m r� which requires a permit to construct, alter, improve, demolish, or repair any structure Z y prior to its issuance, also requires the applicant for such permit to file a signed statement < that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 rt= (commencing with Section 7000) of Division 3 of the Business and Professions Code) or i 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 not more than five hundred dollars (5500). ❑ 1, 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 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:) fits 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 contractor(s) licensed pursuant to the Contractor's License Law. ❑ I am exempt under Sea B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: O z� W? aQ ►`O z UO w F, OU eF-t Vl U 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compcn- sation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. —1 I have and will maintain Worker's Compensation Insurance, as required by Section 3710 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: u Carrier. I HC zeMITR Policy No.: C0(0 302H 01 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) 1 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 Worker's Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (See. 3097, Civ. C.) Lender's Name Lender's Address 1 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 building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. (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 in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SgCEGULATI gn�S. � O Signature ofApplicant/Contractor �6au: HAZARDOUS MATERIALS DISCLOSURE 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 Safely Code, Section 25532(a)? ❑ yes )kNo Will the applicant or future building occupant use equipment or devices which ,:mit hazardous air contaminants as defined by the Bay Arca Air Quality Management District? ❑Yes �)1u 1 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 does not currently have a tenant, that it is my responsibility to notify the occupant of the reyu' me must be m t prior issuance of a Certificate ;; Occupancy. Owner or authoriz d agent F' Z Dais PLUMBING 3345 SELDON CT (510)376-4816 PERMIT No. 06100007 PERMIT ISSUE DATE 10/02/2006 SANITARY NO. CONTROL NO. BUILDING PERMIT INFO BLDG ELECT PLUMB Job Description WATER HEATER REPLACEMENT . Ft. Floor Area Required Inspections Issued by: Re -roofs Type of Roof Date Valuation All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant All roof coverings to be Class "B" or better Date CITY OF CUPERTINO :m 1 of 1 PERMIT RECEIPT OPERATOR: amyw COPY # : 2 Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 37539034.00 DATE ISSUED.......: 10/02/2006 RECEIPT #.......••: 36273 REFERENCE ID # ...: 06100007 SITE ADDRESS 930 BROOKGROVE LA SUBDIVISION ....... CITY CUPERTINO IMPACT AREA ....... OWNER ............: DYMLING STEN ADDRESS .. ....... CITY/STATE/ZIP ...: , RECEIVED FROM ....: ALL VALLEY PLUMBING CONTRACTOR .......: MARY SANDBRINK LIC # 23015 COMPANY ..........: ALL VALLEY PLUMBING ADDRESS ..........: 3345 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 NUMBER ------------------ ----------------- ------------ CHECK 84.02 7489 TOTAL RECEIPT 84.02 VOICE ID DESCRIPTION VOICE ID DESCRIPTION ---=---- ---------------------------- 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING CUPEkTINO CITY OF CUPERTING WATER HEATER PERMIT APPLICATION FORM APN # Date: BUILDING PLUMBING BUILDING BUILDING Building Address: ��d r� Lin . Cv Phone #: Owner's N e: vi o #: Contractor / P n �v License 79 Contact: � one• �e�� Cupertino B sines License #: ren Building Permit fo: Bld ❑ Elect ❑ Plumb Mech ❑ Job Description:J D L74 �C� Residential Commercial ❑ Cost of Project: �) Strapped On Platform El Bonded New Location Replacement Qty. if uoe ricvor;r%tinn Fee Group Alicable Fee W BPWHEATER PPERMITFEE B ENERGY B ENER 1 "" "_"" `—— Water Heater / Vent Permance Plumbingit Issu Ener Business License BUILDING PLUMBING BUILDING BUILDING