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09090109 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10141 FIRWOOD DR CONTRACTOR:FAST WATER HEATER PERMIT NO:09090109 OWNER'S NAME: DUTT,SIMA 12601 132 AVE NE DATE ISSUED:09/15/2009 ER'S PHONE: 4088588223 KIRKLAND,WA 98034 PHONE NO:(800)454-8955 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F ELECT f— PLUMB License Class Lic.# MECH f- RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE/REPLACE GAS 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 Sq.Ft Floor Area: Valuation:$1025 performance of the work for which this permit is issued. 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 APN Number:34233028.00 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.1 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 granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Signature Date RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is G OWNER-BUILDER DECLARATION installed without first obtaining an inspection,I agree to remove all new materials for inspection. 1 hereby affirm that 1 am exempt from the Contractor's License Law for one of the following two reasons: Signature of Applicant: Date: 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) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE I hereby affirm under penalty of perjury one of the following three I have read the hazardous materials requirements under Chapter 6.95 of the declarations: California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain I have and will maintain a Certificate of Consent to self-insure for Worker's compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should I store or handle hazardous material. performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air I have and will maintain Worker's Compensation Insurance,as provided for by contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Section 3700 of the Labor Code,for the performance of the work for which this Health&Safety Code,Sections 25505,25533,and 25534. permit is issued. I certify that in the performance of the work for which this permit is issued,I shall Owner or authorized agent: not employ any person in any manner so as to become subject to the Worker's Date: 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 CONSTRUCTION LENDING AGENCY forthwith comply with such provisions or this permit shall be deemed revoked. I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued(Sec.3097,Civ C.) APPLICANT CERTIFICATION Lender's Name 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 Lender's Address to building 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 nify and keep harmless the City of Cupertino against liabilities,judgments, 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: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 34233028 . 00 DATE ISSUED. . . . . . . : 09/15/2009 RECEIPT #. . . . . . . . . : BS000008685 REFERENCE ID # . . . : 09090109 SITE ADDRESS . . . . . : 10141 FIRWOOD DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER DUTT, SIMA ADDRESS 10141 FIRWOOD DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : JEFF JORDAN CONTRACTOR . . . . . . . : JEFF JORDAN LIC # 29100 COMPANY FAST WATER HEATER ADDRESS 12601 132 AVE NE CITY/STATE/ZIP . . . : KIRKLAND, WA 98034 TELEPHONE (800) 454-8955 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 1, 025 . 00 1 . 00 0. 00 1. 00 0 . 00 1BSEISMICR VALUATION 1, 025. 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 Permit No: 04 09 01 O� 457756 dPlain (office use only) City Of Cupertino Building Permit Application E-Mail: Building-Permits@cupertino.ora (Address is case sensitive). Jobsite Address:10141 FIRWOOD DR Date: gp5lQ`l Assessor's Parcel Number: 34„9�z vv Owners Name: DUTT, SIMA Phone No: (408)858-8223 Project Valuation: I(f),pS--r Building Permit Info: Bidg Elect Plumb x Mech Job Description Remove/Replace Gas Water Heater Contractor Information Company Name: FAST WATER HEATER COMPANY Phone No: Contact Name: Julie Caskey Fax No: 425-636-7084 Address: 12601 132ND AVE NE E-mail:carolr@fastwaterheater.com City, State & zip code: KIRKLAND, WA 98034 State Contractor's Lic. No: 877489 Expiration Date: 5/31/10 Worker's Comp No: A09304455 Expiration Date: 12/1/09 Carrier. Truck Insurance Exchange City of Cupertino Business License No: 29100 Credit Card Information Credit Card No: 4417123044992443 Expiration Date: 11/10 Name on Card: Jeff Jordan Visa ❑X MasterCard ❑ American Express ❑ The Building permit application and a completed & signed contractor/subcontractor form need to be submitted with each permit. Community,1Devetopmen + 14300 Torre Avenut Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 CUPERTINO - Building Deament [JOB ADDRESS: 10141 FIRWOOD DR FERMT# �Q �(� I�� OWNER'S NAIYlE: DUTT, SIMA PHONE# (408)858-82213 GENERAL CONTRACTOR-FAST WATER HEATER COMPAN FAX# 425-636-7085 I am not using any subcontractors: Com' ' ��P 9/14/09 Signature Date Please check applicable subcontractors and com Tete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets&h0work CementFinishing IIectrical Excavation Fencing Flooring.Carpeting Linoleum/Wood Glass/Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plashing Plumbing Roofing Septic Tank Sheet Metal Sheet Rock T"xle Owner/Contractor Signature Date