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09010099 CITY OF CUPERTINO WALDING DIVISION PERNIIT fit TRA Q I }R TIMI . PERMIT NO. BUILDING ADDRESS: 21 973 ( AqrrT,F.TnN qrr PERMIT ISSUE DATE OWNER'S NAME: 12601 13-2—AVE NEA CONTROL NO. .r0 � O 4 4-8 BUILDING PERMIT INFO ARCHII.CrfENGINEER: BLDG ELECT PLUMB MECH Z O p LICENSED CONTRACTOR'S DECLARATION Job Description U3 C I hereby affirm that I am licensed under provisions of Chapter 9(commencing Z(�� with Section 7000)of Division 3 of the Business and Professions Code.and my license is n=y in full force and effect. RMV/RPLC WATER HEATER , v�Z License Class Contractor 3 F Dam ARCHITECTS DECLARATION a C< 1 understand my plans shall be used as public records �aU 4 o H Licensed Professional aOWNER-BUILDER DECLARATION 2 fl 2� 1 hereby affirm that 1 am exempt from the Contractors License Law for the Ofollowing reason.(Section 7031.5•Business and Professions Code:Any city or county K m�. which requires a permit to construct.alter,improve,demolish,or repair any structure 4—rn prior to its issuance,also requires the applicant for such permit to Ole a signed statement S Ft.Floor Area Valuation :4< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q Y1- (commencing with Section 7000)of Division 3 of Ute 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(55011). 35618057 . OO ❑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 docs 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:)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 contractor(s)licensed pursuant to the Contractor's License Law. C]I am exempt under Sec B&P C for this reason Owner Dare WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a Certificate of Conscnt to self-insure for Worker's Compen- .,etion,as provided for by Section 3700 of the Labor Code.for the performance of the work for which this permit is issued. ❑1 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 Compensation insurance carrier and Policy number are: Carrier. Policy No.: CERTIFICATE 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 Codc,you must ,J z forthwith comply with such provisions or this permit shall be deemed revoked. Z O 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 A Lender's Name aLender's Address U O 1 certify that 1 have read this application and state that the above information is cortt:cL 1 agree to comply with all city and county ordinances and state laws relating to Q V building construction.and hereby authorise representatives of this city to enter upon the aWvc-mcntioncd property for inspection purposes W W (We)agree to save,indemnify and keep harmless the City of Cupertino against 04 ,E hh C.41liabilities,judgments,costs and expenses which may in any way accrue against said City V Z in consequence of the granting of this permit. Date ►�" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SOURCE REGULATIONS. Re-roofs Signature of Applicant/Contractor Date T of Roof HAZARDOUS 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 roofs shall be inspected prior to any roofing material being installed. C]Yes 0 N Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove pit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. hsu ict? ❑Yes ❑No 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 requirements which must be met prier to issuance of a certificate of Occupancy. Signature of Applicant Date All roof coverings to be Class'j "or better Owner or authorized agent Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN 35618057 . 00 DATE ISSUED. . . . . . . : 01/22/2009 RECEIPT # . . . . . . . . . BS000007021 REFERENCE ID # . . . 09010099 SITE ADDRESS 21573 CASTLETON ST SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : LIAN, TIONG-HU ADDRESS 21573 CASTLETON ST CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4702 RECEIVED FROM . . . . : JEFF JORDAN CONTRACTOR . . . . . . . : JEFF JORDAN LIC # 29100 COMPANY . . . . . . . . . . : FAST WATER HEATER ADDRESS . . . . . . . . . . : 12601 132 AVE NE CITY/STATE/ZIP . . . : KIRKLAND, WA 98034 TELEPHONE . . . . . . . . : (800) 454-8955 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- 1BCBSC VALUATION 449 .00 1 . 00 0 .00 1 . 00 0 . 00 1BSEISMICR VALUATION 449 . 00 0 .50 0 . 00 0 . 50 0 . 00 1PPERMITFE FLAT RATE 1 .00 40 . 79 0 .00 40 .79 0 . 00 1PRWHEATR UNITS 1 . 00 24 .48 0 . 00 24 .48 0 .00 1TRAVDOC FLAT RATE 1 .00 40 .79 0 .00 40 .79 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 107 .56 0 . 00 107 . 56 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- ---------------- CREDIT CARD 107 .56 VISA --------------- TOTAL RECEIPT 107 .56 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---- 518 WATER HEATER Permit No: � 09 430613 (office use only) City Of Cupertino Building Permit Application E-Mail: Building-Permits'@Mhert-ino.org (Address is case sensitive). Jobsite Address:21573 CASTLETON ST Date: 1/22/09 Assessor's Panel Number:��(o� 9'o 5`7. u"-�' Owners Name: LIAN, JUNG Phone No: (408)873-8688 Project Valuation: 449.00 Building Permit Info: Bldg Elect Plumb X Mech Job Description Remove/Replace Gas Water Heater Contractor Information Company Name: FAST WATER HEATER COMPANY Phone No: Contact Name: Julie Caskey Fax No: 425-636-7084 Address: 12601 132ND AVE NE E-mail: carolr@fastwaterheater.com - City, State&zip Code: KIRKLAND,WA 98034 State Contractor's Lic. No: 877489 Expiration Date: 5/31/10 Worker's Comp No: A09304455 Expiration Date: 12/1/09 Carrier: Truck Insurance Exchange City of Cupertino Business License No: 29100 Credit Card Information Credit Card No: Expiration Date: 11/10 Name on Card: Jeff Jordan Visa ® MasterCard ❑ American Express ❑ The Building permit application and a completed & signed contractorlsubcontractor form need to be submitted with each permit., Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 CUPI�TINO Btuuung Department JOB ADDRESS: 21573 CASTLETON ST PERAW# Oq 0 O(-)qI OWNER'S NAME: LIAN,JUNG PHONE# (408)873-8688 GENERAL CONTRACTOR:FAST WATER HEATER COMPAN FAX# 425-636-7085 I ant not using any subcontractors:` � 1/22/09 Signature Date Please check a linable subcontractors and com lete the foIlo information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets&Millwork Cement Finishing Electrical Excavation Fencing Flooring Carpeting Linoleum/Wood Glass/Glazing Heating Insulation TM Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tyle Owner/Contractor Signature Date