Loading...
09090187 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20891 MC CLELLAN RD CONTRACTOR:SHAYNE STUBBS PERMIT NO:09090187 OWNER'S NAME: SHAYNE STUBBS 20891 MC CLELLAN DATE ISSUED:09/25/2009 t VER'S PHONE: 6502732271 CUPERTINO CA, 95014-2957 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATIONf— BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH f- RESIDENTIAL f- COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TANKLESS 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:$1500 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 APN Number:35913083.00 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 granting of this permit. Additionally,the applicant understands and will comply Issued bye ✓-�✓'" Date: 6�� 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 to OWNER-BUILDER DECLARATION installed without first obtaining an inspection,I agree to remove all new materials for inspection. I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: Signature of Applicant: Date: 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, ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER Business&Professions Code) 1,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 deft by the Bay Area Air Quality Management District I will maintain complianc 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 C e ections 25505,25533,and 25534. permit is issued. l certify that in the performance of the work for which this permit is issued,1 shall O or t7uo ' e t: Q9/ not employ any person in any manner so as to become subject to the Worker's Date: ` C' 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.1 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 rnify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which m accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Ad tionally,the applicant understands and will comply with all non-poi sourc egu ns per the Cupertino Municipal Code,Section Licensed Professional 9.18. / Signatu Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 35913083 . 00 DATE ISSUED. . . . . . . : 09/25/2009 RECEIPT #. . . . . . . . . : BS000008768 REFERENCE ID # 09090187 SITE ADDRESS . . . . . : 20891 MC CLELLAN RD SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER SHAYNE STUBBS ADDRESS 20891 MC CLELLAN CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2957 RECEIVED FROM . . . . : SHAYNE STUBBS CONTRACTOR LIC # *OWNER* COMPANY SHAYNE STUBBS ADDRESS 20891 MC CLELLAN CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2957 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 1, 500 . 00 1 . 00 0 .00 1. 00 0 . 00 1BSEISMICR VALUATION 1, 500 . 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 AMEX --------------- TOTAL RECEIPT 110 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 518 WATER HEATER Ogv9 / � CITY OF CUPERTINO 10 WATER HEATER PERMIT APPLICATION FORM CUPERTINO APN # Q ` � i� � Date: 6/4V Building Address: &Dgf/ Ale&s«44) R:4 Owner's Name: Phone #: ; Ue;roc v665 X50. 273 • 27- 71 Contractor: Phone #: DGJivc,,r- 11 Fax #: Cupertino Business License #: Contractor State License #: Contact: Phone #: Fax #: Building Permit Info: 'j"� k�e�3 c.J.•:t�.- t��h-l �,z= Bldg Elect Plumb Mech ❑ Residential (�' Commercial ❑ Solar ❑ If solar, number of kilowatts: Strapped On Platform ❑ Bonded New Location Replacement Valuation (cost of project): Z I l�Zn _ 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: 62— Revised 08/20/09 CITY OF CUPERTINO WATER HEATER PERMIT APPLICATION FORM CUPERTINO Quantity Fee I D Fee Description Fee Permit Type Group 1 PC WBEATR Commercial Water B P C W H E A T R HeaterNent 1 BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee IBSEISMICOM Seismic Commercial B 1 PRWI EATR Residential Water B P R W H E A T R HeaterNent 1 BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICRE Seismic Residential B 1 PPERMITFEE Plumbing Permit P 1 TRAVDOC Travel & B Documentation 1 BUSLIC Business License B OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate family (parent,spouse or child) will perform: A. All the work authorized by this permit B. _ A portion of the work C. None of the work If B or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hired to do: A. _ All of the work B. A portion of the work (complete section below) Contractor Address/City Phone # State License # Type of work to be performed 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. PersorVFirm Address/City Phone Number Type of work to be erformed ........................................................................... ......................................................................................................... I declare under penalty of perjury that th a e is true and correct. I have read and understand the Owner-Builder Information (re a sid Property Owner's Signature: Date: d Job Address: 204q! A,44-4 !— e-1140 1W Permit# O / O / ©`� Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department.