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09100126 _ CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10341 MANN DR CONTRACTOR:AFFORDABLE WATER PERMIT NO:09100126 HEATERS& OWNER'S NAME: CLEWETT RICHARD A AND REBECCA 24663 RAILROAD AVE DATE ISSUED: 10/21/2009 ..NER'S PHONE: 4082182089 SANTA CLARITA,CA 91321 PHONE NO:(661)259-7131 ❑ LICENSED CONTRACTOR'S DECLARATIONF BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class fir`' (' Z 7 Ifo � � MECH f- RESIDENTIAL r COMMERCIAL r Contractor )O7 G-' Date t d Z I I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE WATER HEATER,SAME LOCATION (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two 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 Sq.Ft Floor Area: Valuation:$1400 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 APN Number:32645029.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. 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 Issued Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. r l S;--,ature J�i�Z-�" Date RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is ,❑ OWNER-BUILDER DECLARATION installed without first obtaining an inspection,I agree to remove all new materials for inspection. I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: Signature of Applicant: Date: 1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the stricture is not intended or offered for sale(Sec.7044, ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to constrict the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE I hereby affirm under penalty of perjury one of the following three I have read the hazardous materials requirements under Chapter 6.95 of the declarations: California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain a Certificate of Consent to self-insure for Worker's compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should I store or handle hazardous material. performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air I have and will maintain Worker's Compensation Insurance,as provided for by 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 Section 3700 of the Labor Code,for the performance of the work for which this Health&Safety Code,Sections 25505,25533,and 25534. permit is issued. I certify that in the performance of the work for which this permit is issued,I shall Owner or authorized agent: �/7 6`1 not employ any person in any manner so as to become subject to the Worker's c� C � Date: 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 CONSTRUCTION LENDING AGENCY forthwith comply with such provisions or this permit shall be deemed revoked. 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.) APPLICANT CERTIFICATION Lender's Name 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 Lender's Address to building construction,and hereby authorize representatives of this city to enter the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION .mify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date CITY OF CUPERTINO 5 ITEMS OF 35 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32645029 . 00 DATE ISSUED. . . . . . . : 10/21/2009 RECEIPT #. . . . . . . . . : BS000008982 REFERENCE ID # . . . : 09100126 SITE ADDRESS . . . . . : 10341 MANN DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER CLEWETT RICHARD A AND REBECCA ADDRESS . . . . . . . . . . : 10341 MANN DR CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-1139 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, 400. 00 1. 00 0 .00 1. 00 0 .00 1BSEISMICR VALUATION 1,400. 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 $ATE 1. 00 42 .00 0 . 00 42 . 00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 110 .50 0. 00 110 . 50 0 . 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 518 WATER HEATER CITY OF CUPERTINO "annoWATER HEATER CUINO PERMIT APPLICATION FORM APN # Date: . 2G 5-0Z9 . v Building Address: j u 3 H I M^r rn fir, Owner's Name: Phone #: Contractor: Phone #: 6 6 I-- A-51 " 713 1 A Fford,ahl� WM-e-r pe-ai-e.rs Fax #: Cupertino Business License #: Contractor State License #: ,-6 klS-D (0-736ff Contact: Phone #: D c_C)I-t Fax #: Building Permit Info: Bldg ❑ Elect [ Plumb Mech � - Residential L] Commercial ❑ Job Description: Strapped NJ On Platform ❑ Bonded New Location ❑ Replacement Valuation: Cavo ., Green Building Check must be completed and attached to this application. Green Building Points achieved: CITY OF CUPERTINO WATER HEATER G CUPER,TINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Permit Type Group 1 PCWHEATR Commercial Water B PCWHEATR HeaterNent BSEISMICOM Seismic Commercial B I PRWHEATR Residential Water B PRWHEATR HeaterNent f BSEISMICRE Seismic Residential B PPERMITFEE Plumbing Permit P TRAVDOC Travel & B Documentation BUSLIC Business License B Community Development ti 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF �UPEf�TINO Fax(408)777-3333 Building Department JOB ADDRESS: PERMIT # I X3-1 1 Mir, r\ or. Uq ( 0701 OWNER'S NAME: �C 1n C l t w L t-7- PHONE # e d(fir a Ck GENERAL CONTRACTOR: t�-FF- ru 0--)114 FAX # I am not using any subcontractors: jtw-q,- ,-- ignature Date Please check applicable subcontractors and complete the following information: 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 0 Owner/ tractor Signature Date