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09080149 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21742 COLUMBUS AVE CONTRACTOR:AFFORDABLE PERMIT NO:09080149 WATER HEATERS & OWNER'S NAME: MURRAY PETER F AND JILL 24663 RAILROAD AVE DATE ISSUED:08/17/2009 . VVNER'S PHONE: 408255336 SANTA CLARITA,CA 91321 PHONE NO:(661)259-7131 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB License Class 'CA'C-- Lic.# C►27 509 �... 'T� MECH RESIDENTIAL 1 COMMERCIAL Contractor��yy� Date 1 hereby affirm that I am licensed under the provisions of tapter 9 JOB DESCRIPTION: REPLACE WATER HEATER (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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$1400 1 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. APN Number:35618043.00 Occupancy Type: 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; to building construction,and hereby authorize representatives of this city to enter WITHI� 180 DAYS OF PE"IT ISSUANCE OR upon the above mentioned property for inspection purposes. (We)agree to save 180 D� S FROM L ICALLED 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 with all non-point source regulations per the Cupertino Municipal Code,Section granting of this permit. Additionally,the applicant understands and will comply Issued by: `' ® Date: V r 9.18. c` n Date 7 © RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is _ installed without first obtaining an inspection,1 agree to remove all new materials for ❑ OWNER-BUILDER DECLARATION inspection. I hereby affirm that 1 am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation. ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE 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. 1 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(a)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 b the Ba Area Air Y Y Quality Management District I performance of the work for which this 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 permit is issued. Owner or authorized agent: 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 CONSTRUCTION LENDING AGENCY 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 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 9 the above mentioned property for inspection purposes.(We)agree to save mnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION 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 Community Development t 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF ';U PE�TINO Fax(408)777-3333 Building Department JOB ADDRESS`7 �� �l � �v c PERMIT # OWNER,S NAME: PHONE # GENERAL CONTRACTOR: FAX # f a 2 g�5 t4fr-, 7a, r2S Pc-�-c w� L✓ n Z.4.c�_ I am not using any subcontractors: _�— 7 ( 5 gnature Date Please check applicable subcontractors and complete the following information: 60 SUBCONTRACTOR BUSI14ESS 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 �K PlumbingFo� Roofing Septic Tank Sheet Metal Sheet Rock Tile _ 7r fz 1 er/Contractor Signature Date CITY OF CUPERTINO T, WATER HEATER OF CUPEkTINO PERMIT APPLICATION FORM 6 qMb Pe-) ci APN # 00 Date: -7_ 31 - D� Building Address: 4k-1 LA C0 LA r,) ALX V� v� Owner's Name: Phone #: J � lk rnLA( rey y33310 Contractor: Phone #: A 51 - 7 13 1 Agffor-dahle w4W Fax #: (o to I -ls-y- '15';-6 Cupertino Business License #: Contractor State License #: Contact: Phone #: (� - ,�s9 o 54.o $cofifi LittleFf e Ict Fax #: (061 -� 5�- gsSb Building Permit Info: Bldg ❑ Elect ❑ Plumb Mech ❑ Residential N] Commercial ❑ Job Description: So.(V-\ L l 0 cc,+ Dr Strapped On Platform ❑ Bonded New Location ❑ Replacement Valuation: N o o Green Building Check must be completed and attached to this application. Green Building Points achieved: CIT I' OF CUPERTI` O N'�'A'i, ;R E(ECITY OF ATE R.. CUPERTINO PERIMIT APPLICATION FORM Quantity Fee ID Fee Descript ion Fee Permit Type Group 1PCWHEATR Commercial Water B PCWHEATR HeaterNent BSEISMICOM Seismic Commercial B ' 1 PRWHEATR Residential V Vater B PRWHEATR HeaterNent r BSEISMICRE Seismic Residential B PPER 41TFEE Plumbing Permit P J TRAVDOC Travel & B Documentation BUSLIC Business License B