10040105 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18974 PENDERGAST AVE CONTRACTOR:TBD-TO BE PERMIT NO: 10040105
DETERMINED
WNER'S NAME: CAROL MATTSSON DATE ISSUED:04/16/2010
OWNER'S PHONE: 4082553767 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL
License Class Lie.# INSTALL WATER HEATER
Contractor Date
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. Sq.Ft Floor Area: Valuation:$1300
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:37534041.00 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 b Date:
granting of this permit. Additionally,the applicant understands and will comply 3'
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
;nature 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 exempt 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)
I,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. 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(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 by the Bay Area Air 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 255'05,25533,and 5534. 1
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: (/vJ"O"t C ate: y 0'
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
correct.I agree to comply with all city and county ordinances and state laws relating
building construction,and hereby authorize representatives of this city to enter
m the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
.,demnify 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. I
Signature t!/�`��J� �t�/'� vateC�
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 37534041 . 00
DATE ISSUED. . . . . . . : 04/16/2010
RECEIPT #. . . . . . . . . BS000010205
REFERENCE ID # . . . : 10040105
SITE ADDRESS 18974 PENDERGAST AVE
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER CAROL MATTSSON
ADDRESS 18974 PENDERGAST AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : CAROL MATTSSON
CONTRACTOR TBD - TO BE DETERMINED LIC # 00096
COMPANY TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 1, 300 .00 1. 00 0 . 00 1. 00 0 . 00
1BSEISMICR VALUATION 1, 300 . 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
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 110 . 50 visa
---------------
TOTAL RECEIPT 110. 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER
CITY OF CUPERTINO
WATER HEATER
CUPEi�T1NO PERMIT APPLICATION FORM
iqo 106
APN# Date:
-7 5
Building Address:
Cu �� rn o q,orte- .�
Owner's Name: Phone #:
Contractor: Phone #:
( f� 1) Fax #:
Cupertino Business License #: Contractor State License #:
Contact: Phone-#--- <f Og) 9.`r- A- /
Ccxr0 SSO✓S,
Fax #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Residential M Commercial ❑
Job Description:
Strapped ❑ On Platform ❑ Bonded ❑ New Location ❑ Replacement
Valuation (cost of project): * 1300
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.
Green Building Points achieved:
Revised 03/10/10
CITY OF CUPERTINO
WATER HEATER
I�
CUPETiNO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCWHEATR Commercial Water B PCWHEATR
HeaterNent
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fee
1BSEISMICOM Seismic Commercial B
1PCSWHTR Commercial Solar B PCSWHTR
Thermal Water Htr
f 1PRWI-iEATR Residential Water B PRWHEATR
HeaterNent
1PRSWHTR Residential Solar B PRSWHTR
Thermal Water Htr
t 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fee
1BSEISMICRE Seismic Residential B
1PPERMITFEE Plumbing Permit P
I 1 TRAVDOC Travel & B
Documentation
1BUSLIC Business License B