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10060084CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21373 DEXTER DR ("` NER'S NAME: PARK AND JOAN B CHAMBERLAIN G,*NER'S PHONE: 4084464704 ❑ LICENSED CONTRACTOR'S DECLARATION License Class 3 6 Lic. # ��3 J" 3 nn/� � 7�//) #_, Date b�V l U Contractor p'� � v�� I hereby affirm that I 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. 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 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. P tutp-A 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 re I tions per the upertino Municipal Code, Section 9.18. c ; ^naturen1_1 ate ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1, 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 to building construction, and hereby authorize representatives of this city to enter n the above mentioned property for inspection purposes. (We) agree to save mnify 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 CON'rRACTOR: ANDREW K MILLS PLUMBING INC PERMIT NO: 10060084 1306 IZEAMWOOD AVE DATE ISSUED: 06/15/2010 SUNNYVALE, CA 94089 PHONE NO: (408)938-1395 BUILDING PERMIT INFO: BLDG ELECT F PLUMB MECH RESIDENTIAL r— COMMERCIAL JOB DESCRIPTION: REPLACE WATER HEATER 50 GAL Sq. f t Floor Area: Valuation: $1495 APN Number: 32641087.00 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR [80 DAYS FROM LAST CALLED INSPECTION. Issued by_-,_ Date: s'l> _014 RE -ROOFS: All r )ofs 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 inspi action. 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 & Saft ty Code, Section 25532(a) should I store or handle hazardous material. Ade itionally, should I use equipment or devices which emit hazardous air coni aminants as defined by the Bay Area Air Quality Management District I will mai itain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Ow rer or authorized agent: / ✓ Sv �/J r Q Date: (g CONSTRUCTION LENDING AGENCY I he •eby affirm that there is a construction lending agency for the performance of work's for vhich this permit is issued (Sec. 3097, Civ C.) Lender's Name Len der's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Lic ,-nsed Professional CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: ,F_( yt_ Diz PERMIT # �o OWNER'S NAME: r1& Nn PHONE # �406'— GENERAL CONTRACTOR: %V V RF -,4l fe-, %i ffS BUSINESS LICENSE # Z v 0 ADDRESS: -1306 7 1 CITY/ZIPCODE: jVN vR k , e1F . QYod *Our municipal code requires all businesses working in the city to nave a t-ity of t_,uperuno uusiuess uCCUNC. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTOR AVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: r Signature Please check applicable subcontractors and complete i he following information: 6 - �5 -2'0//P Date Ownerk/ Contractor Signature /s= '� vr'o Date 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 X Plumbing Q / 14i ,w. �, �-+ S / 6w► D Roofing Septic Tank Sheet Metal Sheet Rock Tile Ownerk/ Contractor Signature /s= '� vr'o Date 4 ITEMS OF 4 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lct: APN ........: 326410£7.00 DATE ISSUED.......: 06/15/.010 RECEIPT #......... BS0000:.0627 REFERENCE ID # 100600£4 SITE ADDRESS 21373 DEXTER DR SUBDIVISION ...... CITY CUPERT:-LNO IMPACT AREA ...... OPERATOR: patg COPY # : 1 OWNER PARK AJD JOAN B CHAMBERLAIN ADDRESS ..........: 21373 DEXTER DR CITY/STATE/ZIP ...: CUPERTINO, CA RECEIVED FROM ANDREW K MILLS CONTRACTOR ANDREW K MILLS LIC # 23504 COMPANY ANDREW K MILLS PLUMBING INC ADDRESS . 1306 REAMWOOD AVE CITY/STATE/ZIP SUNNYVALE, CA 94089 TELEPHONE (408)938-1395 FEE ID UNIT QUANTITY AMOCNT PD -TO -DT ---------- THIS REC -- -- NEW -BAL- ---------- 1BCBSC ------------- VALUATION ---------- 1,495.00 ---------- 1.00 0.00 1.00 25.00 0• 00 0.00 1BPWHEATER PER HEATER 1.00 25.00 0.00 0.00 42.00 0.00 1PPERMITFE FLAT RATE 1.00 42.00 42.00 0.00 42.00 1TRAVDOC FLAT RATE 1.00 ---------- ---------- ------0_00 ---------- :.10.00 0.00 110.00 0.00 TOTAL PERMIT METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 110.00 --------------- 110.00 VOICE ID DESCRIPTION -------- ---------------------------- 518 WATER HEATER REFERENCE NUMBER --------------------- V'-SA VOICE ID DESCRIPTION -------- --------- ------------------ CITY OF CUP'ERTINO WATER HEATER PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group_ Permit Type 1PCWHBATR Commercial Watcr HeaterNent B PCWHEATR 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICOM Seismic Commercial B 1PCSWHTR Commercial Solar Thermal Water Fltr B PCSWHTR 1PRWHEATR Residential Water HeaterNent B PRWHEATR IPRSWHTR Residential Solar Thermal Water Htr B PRSWHTR IBCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICRE Seismic Resideny:ial B 1PPERMITFEE Plumbing Permit. P 1 TRAVDOC Travel & Documentation B 1 BUSLIC Business Licens � B