11010074 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 934 BLAZINGWOOD AVE CONTRACTOR:ALL VALLEY PLUMBING PERMIT NO: 11010074
OWNER'S NAME: ERIC S WU 3345 SELDON CT DATE ISSUED:01/13/2011
OWNER'S PHONE: 4083209348 FREMONT,CA 94539 PHONE NO:(510)3764816
rrs. LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB r
ficense Ctass Lic.# `7�`t^r
MECH[_ RESIDENTIAL r— COMMERCIAL�
Contractor Date tit l-slid _ V-
I
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:WATER HEATER REPLACEMENT 50GAL,LIKE FOR LIKE
(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.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$700
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:36917011.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS F AST CALLED INSPECTION.
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. Issued by: Date:
Signature Date t '
OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
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, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
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 O oto r autTiol'i ed agent:
become-subject to the Worker's Compensation provisions of the Labor Code,I must Date: ®t 13
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
r and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
ng of this permit.Additionally,the applicant understands and will comply
wiw all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
5 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36917011.00
DATE ISSUED. . . . . . . : 01/13/2011
RECEIPT #. . . . . . . . . : BS000012466
REFERENCE ID # . . . : 11010074
SITE ADDRESS . . . . . : 934 BLAZINGWOOD AVE
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER ERIC S WU
ADDRESS . . . . . . . . . . : 934 BLAZINGWOOD AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4619
RECEIVED FROM . . . . : ALL VALLEY PLUMBING
CONTRACTOR . . . . . . . : MARY SANDBRINK LIC # 23015
COMPANY . . . . . . . . . . : ALL VALLEY PLUMBING
ADDRESS . . . . . . . . . . : 3345 SELDON CT
CITY/STATE/ZIP . . . : FREMONT, CA 94539
TELEPHONE . . . . . . . . : (510) 376-4816
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 700 . 00 1.00 0. 00 1. 00 0 .00
1BSEISMICR VALUATION 700 . 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
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 934 Blazingwood Ave DATE: 01/13/2011 REVIEWED BY:
APN: BP#: *VALUATION: $700
;PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Water Heater
PRIMARY SFD or Duplex 11. PENTAMATION PRWHEATR
USE: P �' -t�«�-� � PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY BP FEES
Water Heater/Vent Unit Fee: 1 PRWHEATR 1 $25
Af-,',.h. PlanPlanf Ch,(k 7r t�jt€rfri� I�'Terri C"Ix�r�h fii� �. F,ern C rr,,e_t
[Plumb.Permit Fee: IPPERMIT F7,c, P rmia T,�a
C)tlrc'r ;l�ccdr. Ins,. t)trrz': F">,=rnh Ir;,>_ $42.00 (>Ilrt t;r'i�r./rrsF�.
NOTE. Thesefees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS (Fee Resolution 09-051 Eff ;i1i101 FEE QTY/FEE MISC ITEMS
F'lon C'lreck 11'(A":
.5trppL Fee
F'lrrrnlr.;11'c:Ir..l;lr'c:f'lorr
Sinop/. Irr.Rp Fc,"
PME Unit Fee: $25.00
PME Permit Fee: $42.00
Corrst1*11c71oyr 7',Ly
1t:;ot#S1tCtt1 I(,viciv
Work Without Permit? 0 Yes (F) No $0.00
I�ILZYI!'7777�7 1`ec.:
Travel Documentation Fee: 1 TRAVDOC $42.00
Strong 'Votion Fec:: Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $110.00 $0.00 TOTAL FEE: $110.00
Revised: 12/07/2010
Building Department
City Of Cupertino
Is 10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: PERMIT#
OWNER'S NAME: PHONE#
GENERAL CONTRACTOR: all BUSINESS LICENSE#
ADDRESS:3 t $ CITY/ZIPCODE: F —0--C 3f Ag
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: — g r '3�1
Signature Date
Please check applicable subcontractors and complete the following information:
V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing All te)O
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Otlt3tr�
Owner/Contractor Signature Date
CITY OF CUPERTINO �f
WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
oil cit
Building Address:
114 z ; ,�5 Co a O C 0
Owner's Name: Phone #:
r ; c 3�a - �1 � ��
Contractor: Phone
!/l e 1 % n Fax #: 510-- 0(01 Z)q 7
Cupertino Business License #: Contractor State License #:
CP
Contact: Phone #:5;70— (a _ X095`
a 61 5a nor bt-n I< Fax #: 5/0 --(2 C�2 l-- �!7
Building Permit Info:
Bldg ❑ Elect ❑ Plumb g—'' Mecht�j
Residential Commercial ❑
Job Description:
Se r� L i kt� ATZ tii 1c`�
V 1210 Ce-,r-rnC
Strapped On Platform Bonded New Location ❑ Replacement
Valuation (cost of project): .�
Project Size: Express ❑ Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to
the application or if applicable, include in plan set & the sheet index.
.reen Building Points achieved:
Revised 6/16/08