09050051 CITY OF CUPERTINO -
WJILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
20644 ACADIA CT I FAST WAFER HEATER (19n,nnS1
OWNER'S NAME: PERMIT ISSUE DATE
>Ne?1 T 7 T Tl MG „n 12601 -13 2 A B
S A CONTROL NO.
(800) 454-8955
ARCHTTEC IENGINEER: BUILDING PERMIT INFO
BLDG ELECT� PLUMB� �7
.0 p` LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
M with Section 7000)of Division 3 of the Business and Professions Code,and my license is
=H in full force and effect. RMV/RPI,C GAS WATER HEATR
D to Z License Class Lic.N
F p Date Contractor
ARCHITECT'S DECLARATION
0
U l understand my plans shall be used as public records
o y Licensed Professional
o7 y 3 OWNER-BUILDER DECLARATION
+� 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
i to O following reason.(Section 703 I.S.Business and Professions Code:Any city or county
K$ which requires a permit to construct.alter,improve,demolish,or repair any structure
y Z y prior to its issuance,also requires the applicant for such permit to rile a signed statement
G riot he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
X $ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of $1500
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than fi 500)
rive hundred dollars(5
t,as owner of the or m employees with wa 32656018 . 00
❑ PraP�'• Y wages as their sale compensator,
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 Required Inspections
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.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 die property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Bovines 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.
❑1 am exempt under Sec B dt P C for this reason
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-insure for Worker's Compen-
nuon,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 am:
Carrier: Policy No
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(7Lis section need not be completed if the permit is for one hundred dollars($100)
or less.)
I cerdfv 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.Dab,
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
rJ O forthwith comply with such provisions or this permit shall be deemed revoked.
Z
0-4 CONSTRUCTION LENDING AGENCY
.r 0Y)
�+►- I hereby affirm that there is a construction lending agency for the performance of
LY.> Use work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
ILI
Q z Lender's Address
V Q 1 certify that I have read this application and state that the above information is
iy cored.I agree to comply with all city and county ordinances and state laws relating to
Q V building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
H a (We)agree to save,indemnify and keep harmless the City of Cupertino against
►,t C.4) liabilites,judgments,costs and expenses which may in any way scenic against said City
V Z in consequence of the granting of this permit.
�+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. _
Q
Signature of Applicant/Contractor Dam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type(f Roof
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(x)?
❑Yes ❑No All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection,I ill the applicant or future building occupant use equipment or devices which g agree to remove p g
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 k 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 prior to issuance of a Certificate of Occupancy. Signal ure of Applicant Date
Owner or authorized agent Date
All roof coverings to be Class's or better
g
Permit No: Cq 0` ? 00-D 441435
(office use only)
City Of Cupertino Building Permit Application
E-Mail: Buildinq-PermitsOcupertino.orq (Address is case sensitive).
Jobsite Address:20644 ACADIA CT Date: 4/20/09
Assessor's Parcel Number: �?�(P5 (00
Owners Name: MORDO, DAVID Phone No: (408)252-1985
Project Valuation: I I/50o.'7
Building Permit Info: Blda 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 980:4
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: 4417123041349530 Expiration Date: 11/10
Name on Card: Jeff Jordan
Visa NO MasterCard ❑ American Express ❑
The Building permit application and a completed & signed
contractor/subcontractor form need to be submitted with each permit.
Community Development
10300 Torre Avenue
.` Cupertino CA 95014
Telephone(408)777.3228
F Fax(408)777-3333
CUPEkTINO
Building Department
JOB ADDRESS: 20644 ACADIA CT PERMIT#
OWNER'S NAME: MORDO, DAVID ( PHONE# (408)252-1985
GENERAL CONTRACTOR:FAST WATER HEATER COMPAE FAX# 425-636-7085
I am not using any subcontractors:— '`' 4/20/09
Signature Date
Please check applicable subcontractors and complete the following information:
I 66 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
I Cabinets&Millwork
Cement Finishing I
Electrical I
Excavation
IFencing
Flooring:Carpeting I
Linoleum/ Wood I
Glass/ Glazing
I I Heating
IInsulation I
Landscaping
Lathing !
IMasonry I
IOrnamental Sheet Metal
Painting/ Wallpaper
I Paving
Plastering I
I I Plumbing I
I I Roofing I I
Septic Tank I I
I Sheet Metal. I I
I Sheet Rock
Tile I
Owner/Contractor Signature Date