09100188 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11128 SUTHERLAND AVE CONTRACTOR:BETTER WATER PERMIT NO:09100188
HEATERS
NER'S NAME: KOPP ROGER G AND RIENA 3010 RIDGEGATE DR DATE ISSUED: 10/27/2009
OWNER'S PHONE: 4082557009 SAN JOSE,CA 95133 PHONE NO:(408)250-6672
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT PLUMB r
License Class Lic.# MECH r RESIDENTIAL r COMMERCIAL r
Contractor Date
JOB DESCRIPTION: REMOVE AND REPLACE EXISTING 40 GAL
I hereby arm that I am licensed under the provisions of Chapter 9
affirm
(commencing with Section 7000)of Division 3 of the Business&Professions
WATER HEATER
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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$500
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:35617058.00 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 Issued by: Date:
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
018.
- RE-ROOFS:
,,.6nature Date 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.
❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date:
I hereby affirm that I am exejnpt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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) HAZARDOUS MATERIALS DISCLOSURE
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations• Health&Safety Code,Section 25532(x)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for whichthis permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by
the Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:
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 CONSTRUCTION LENDING AGENCY
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 I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information is
-ect.I agree to comply with all city and county ordinances and state laws relating
.wilding construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify 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 5 PERMIT RECEIPT OPERATOR: bethe
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot :
APN 35617058 . 00
DATE ISSUED. . . . . . . : 10/28/2009
RECEIPT # . . . . . . . . . : 99000000049
REFERENCE ID # . . . : 09100188
SITE ADDRESS . . . . . : 11128 SUTHERLAND AVE '
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER KOPP ROGER G AND RIENA
ADDRESS . . . . . . . . . . : 11128 SUTHERLAND AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4731
RECEIVED FROM . . . . : FRANS CARTWRIGHT
CONTRACTOR FRANS CARTWRIGHT LIC # 26514
COMPANY . . . . . . . . . . . BETTER WATER HEATERS
ADDRESS 3010 RIDGEGATE DR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95133
TELEPHONE (408) 250-6672
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- --------
OLBCBSC VALUATION 500 . 00 1 . 00 0 . 00 1 . 00 0 . 00
OLPLMPE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
OLSEISM VALUATION 500 . 00 0 . 50 0 . 00 0 . 50 0 . 00
OLTRVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
OLWTHTR EACH 1 . 00 25 . 00 0 . 00 25 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 110 . 50 0 . 00 110 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 110 . 50 visa
---------------
TOTAL RECEIPT 110 . 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
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518 WATER HEATER