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09100132I CITY OF CUPERTINO BUILDING PERMIT I IBUILDING ADDRESS: 20791 HANFORD DR I HEATERS & OR: AFFORDABLE WATER I PERMIT NO: 09100132 I 4ER'S NAME: MIMGMEI HSU OWNER'S PHONE: 4084463887 ❑ LLICENSED CONTRACTOR'S DECLARATION License Class Lic. # b Z -7 y IDr Contractor ��Date 1 U 2 d I hereby affinif that 1 am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. 1 hereby affirm under penalty of perjury one of the following two declarations: 1 have and will maintain a certificate of consent to self -insure for Worker's Compensation, 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 provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I 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 accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. iture Date 1 B cl ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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 & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation, 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 provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 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 Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I 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 tp'-uilding construction, and hereby authorize representatives of this city to enter the above mentioned property for inspection purposes. (We) agree to save i....cmnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature_ Date 24663 RAILROAD AVE SANTA CLARITA, CA 91321 DATE ISSUED: 10/21/2009 PHONE NO: (661)259-7131 BUILDING PERMIT INFO: BLDG I ELECT f— PLUMB f— MECH f— RESIDENTIAL f COMMERCIAL r— JOB DESCRIPTION:REPLACE WATER HEATER, SAME LOCATION Sq. Ft Floor Area: I Valuation: $1800 APN Number: 32630070.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued I Dater' � RE -ROOFS: 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: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or auth06T�___ / GDate: iy[ L t Ln CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional 5 ITEMS OF 35 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32630070.00 DATE ISSUED.......: 10/21/2009 RECEIPT #.........: BS000008982 REFERENCE ID # ...: 09100132 SITE ADDRESS .....: 20791 HANFORD DR SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ...... OWNER ............: MIMGMEI HSU ADDRESS ..........: 20791 HANFORD DR CITY/STATE/ZIP ...: CUPERTINO, CA 95014 OPERATOR: patg COPY # : 1 RECEIVED FROM ....: SCOTT W LITTLEFIELD CONTRACTOR .......: LEONCE ROUX LIC # 26850 COMPANY ..........: AFFORDABLE WATER HEATERS & ADDRESS ..........: 24663 RAILROAD AVE CITY/STATE/ZIP ...: SANTA CLARITA, CA 91321 TELEPHONE ........: (661)259-7131 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL ---------- 1BCBSC ------------- VALUATION ---------- 1,800.00 ---------- 1.00 ---------- 0.00 ---------- 1.00 ---------- 0.00 1BSEISMICR VALUATION 1,800.00 0.50 0.00 0.50 0.00 1PPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1PRWHEATR UNITS 1.00 25.00 0.00 25.00 0.00 1TRAVDOC FLAT RATE 1.00 42.00 0.00 42.00 0.00 TOTAL PERMIT ---------- 110.50 ---------- 0.00 ---------- 110.50 ---------- 0.00 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 773.50 --------------- 773.50 REFERENCE NUMBER -------------------- MC VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 518 WATER HEATER CITY 0 CUPERT{NO CITY OF CUPERTINO WATER HEATER PERMIT APPLICATION FORM APN # Date: to Building Address: C' Owner's Name: Phone #: f\"% LA- y L10 i Contractor: Phone #: 6 &I - 511 - 713 1 Fax #: X61- 01 - q ( - Cupertino Business License #: Contractor State License #: ,a. b k � D (0-`136 k' Contact: Phone #: (� 4 j - S °j - D 5-J- A Fax #: Building Permit Info: Bldg ❑ Elect ❑ Plumb Mech ❑ Residential Commercial ❑ Job Description: 1c, c -c Wc,;ter L4e4 .( Strapped NJ On Platform ❑ Bonded New Location ❑ Replacement } Valuation: Green Building Check must be completed and attached to this application. Green Building Points achieved: a (0) CUPEkTINO CITY OF CUPERTINO WATER HEATER PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Grou Permit Type PCWHEATR 1 PCWHEATR Commercial Water HeaterNent B BSEISMICOM Seismic Commercial B 1PRWHEATR Residential Water HeaterNent B PRWHEATR BSEISMICRE Seismic Residential B PPERMITFEE Plumbing Permit P TRAVDOC Travel & Documentation B BUSLIC Business License B CITY OF CUPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: PERMIT # OWNER'S NAME: PHONE # q o k ,-t 6 3 f 7 GENERAL CONTRACTOR: FAX # I am not using any subcontractors: jt& -t l 1-7/ Signature Date Please check anolicable subcontractors and complete the following information: - 1-7/off Owner/ Contractor Signature Date SUBCONTRACTOR BUSINESS 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 - 1-7/off Owner/ Contractor Signature Date