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09010014 CITY OF CUPERTINO ZION BUILDING DIVISION PERMIT PERMrr NO. BUILDING ADDRESS: 17 10277 VISTA KNOLL RIALD FAST OWNER'S NAME: PERMrr ISSUE DATE '2809 SA CONTROL NO. O BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH REMV/RPLC GAS WATER HEATER a O p LICENSED CONTRACTOR'S DECLARATION .Job Description m1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Z with Section 70(X))of Division 3 of the Business and Professions Code,and my license is y in full force and effect Dt2z License Class Lic•g c3 Date Contractor ARCHITECTS DECLARATION 1 understand my plans shall be used as public records D,u OWLicensed Professional H:n OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the co following mason.(Section 7031.5,Business and Professions Code:Any city or county a_� 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 Valuation 'E x that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area t- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or y .. that he is exempt therefrom and Ne 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 APN Number Occupancy Type not more than five hundred dollars(5500). [11,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 q p property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements arc not intended or offered for sale.11, 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 builds or improves thereon,and who contracts for such projects with a contractor($)licensed pursuant to the Contractor's License Law. ❑1 am exempt under Sec. B&P C for this mason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a Certificate of Consent to self-insum for Worker's Compen- ,,ation,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 Compensation Insurance carrier and Policy number arc: Chu; 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 certifv 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 Workers Compensation provisions of the Labor Code,you must `Z, forthwith comply with such provisions or this permit shall be deemed revoked. Z O CONSTRUCTION LENDING AGENCY (~i►�. I hereby affirm that there is a construction lending agency for the performance of p� the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lender's Name Z L.endees Address V 0 f certify that I have read this application and state that the above information is LL correct I agree to comply with all city and county ordinances and state laws relating to 0 V building construction,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes. 6L (We)agree to save.indemnify and keep harmless the City of Cupertino against u..4 to liabilities,judgments,costs and expenses which may in any way scenic against said City U Z in consequence of the granting of this permit. Date 0-4 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SOURCE REGULATIONS. Re-roofs Signature of Applicant/Conuactor Date Type of Roof HAZARDOUS MATERIALS DISCLOSURE yP 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 Cade.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes ❑No 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 it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. .strict? ❑Yes ❑No I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&SafetyCodc,Sections 25505.25533 and 25534.1understand thatifthc building does not currently have a tenant,that it is my responsibility to notify the occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. Signature of Applicant Date Owner or authorized agent Date All roof coverings to be Class" ''or better r CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot: APN 32613126 . 00 DATE ISSUED. . . . . . . : 01/05/2009 RECEIPT # . . . . . . . . . . BS000006904 REFERENCE ID # . . . : 09010014 SITE ADDRESS . . . . . : 10277 VISTA KNOLL BLVD SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : SHOVLIN MICHAEL D AND MARIEANN ADDRESS . . . . . . . . . . : 10277 VISTA KNOLL BLVD CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1033 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 ---------- ------------- ---------- ---------- ---------- ---------- ---------- 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 106 . 56 0 . 00 106 . 56 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 106 . 56 VISA --------------- TOTAL RECEIPT 106 . 56 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 518 WATER HEATER Permit No: Oa I q426820 (office use only) City Of Cupertino Building Permit Application E-Mail: Building-Permb(a)-cuper-ino.org (Address is case sensitive). Jobsite Address:10277 VISTA KNOLL BL Date: 1/5/09 Assessor's Parcel Number.3A to l (F I C, Owners Name: SHOVLIN, MIKE Phone No: (408)730-4413 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 Lie. No: 877489 Expiration Date: 5/31/10 Worker's Comp No: 1761660 Expiration Date: 1211/08 Carrier: California State Fund C of Cupertino Business License No: 29100 Credit Card Information Credit Card No: Expiration Date: 1111 o Name on Card: Jeff Jordan Visa MasterCard ❑ American Express ❑ The Building permit application and a completed & signed contractor/subcontractor form need to be submitted with each permit. Commmity Developutent 10300 Torre Avemse Cupertino CA 93014 Telephone(408)777-3228 CUpE#��'INO Fax(409) �-3333 -- Building Department JOB ADDRESS: 10277 VISTA KNOLL BL PERMiT# OWNEZ'S NAME- SHOVLIN, MIKE PHONE# (408)730-4413 I GENERAL CONTRACTOR:FAST WATER HEATER COMPA PAX# 425-636-7085 I am not using azar subcontractors:` � e�. 1/5/09 Signature Date Please check applicable subcontractors and com lete tete following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE# Cabhteis&UMwork Cement p slung Biechical Excavation Perking Flooring:Carpeting Linoleum/Wood Glass/Glazing Heating Insulation Landscaping L,athixz Masonry Ornamental Sheet Metal Painting/Waiipaper Paving Piagter3ng Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date