09050050 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � TRt, Q � RtTt
BUILDING ADDRESS: PERMIT NO.
10680 JOHNSON AVE FAST WATER HEATER 090900so
OWNER'S NAME: PERMIT ISSUE DATE
J3 n T ARS—_zQNT_1
S A CONTROL NO.
(800) 454-8955
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
apo LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business and Professiam Code.and my license is
n H in full Corte and effect RMV/RPL-- GAS WATER HEATER
Z License Class Lk•M
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
X06
4 u. Licensed Professional
y OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
in O following reason.(Section 7031.5.Business and Professions Code:Any city or county
Pi 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
cteat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
y F (commencing with Section 7000)of Division 3 of tie Business and Professions Code)or $1230
N�! that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by say applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500). 37531013 . 00
❑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(See.7044,Business Required Inspections
and Professions Cade:The Contractors 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 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.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractors 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 Contractors
License Law.
❑I am exempt under Sec. B&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 Workers Compcn-
sadon,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 Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carie: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section reed 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,l 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
[~r'fir I hereby affirm that there is a construction lending agency for the performance of
fyc.7
the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lenders Name
]z Landers Address
V O 1 certify that I have read this application and state that the above information is
corecL I agree to comply with all city and county ordinances and state laws relating to
0building construction,and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes
LL (We)agree to save,indemnify and keep harmless the City of Cupertino against
.to liabilities,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 Applicam/Contractor Dale Type Of Roof
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 Safety
Cask,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑yes ❑No
If a roof i;installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
I hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
.strict?
❑Yes ❑Nu
I 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 prior to issuance of a certificate of Occupancy. Signature of Applicant Date
Owner or authorized agent
Date All roof coverings to be Class'R'or better
Permit No: ()q05oo5G 440383
(office use only)
City Of Cupertino Building Permit Application
E-Mail: Building-Permits(c cupertiro.or (Address is case sensitive).
Jobsite Address: 10680 JOHNSON AVE Date: 4/15/09
Assessor's Parcel Number:�?_l S 1251 01
Owners Name: DONTHI, BALARAM Phone No: (408)777-9911
Project Valuation: (ap O
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: 4417123041349530 Expiration Date: 11/10
Name on Card: Jeff Jordan
Visa ❑x MasterCard ❑ American E=xpress ❑
The Building permit application and a completed & signed
contractor/subcontractor form neec to be submitted with each permit.
rti Community Development
s 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CI Of Fax(408)777-3333
CUPEkTINO
Building Department
JOB ADDRESS: 10680 JOHNSON AVE PERMIT# 0905 O v 5 U
OWNER'S NAME: DONTHI, BALARAM PHONE# (408)777-9911
GENERAL CONTRACTOR:FAST WATER HEATER COMPA FAX# 425-636-7085
I am not using any subcontractors:._
4/15/09
Signature Date
Please check applicable subcontractors and com le`e the following information:
SUBCONTRACTOR BUSINE SS 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
Owner/Contractor Signature Date