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09110040 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22971 LONGDOWN RD CONTRACTOR:WATER HEATERS ONLY PERMIT NO:091 10040 OWNER'S NAME: HARPER LEROY AND KIM 970 E MAIN ST DATE ISSUED: 11/09/2009 i ER'S PHONE: 4088875813 GRASS VALLEY,CA 95945 PHONE NO:(800)835-5946 ❑ LICENSED CONTRACTOR'S DECLARATIONF BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH RESIDENTIAL f— COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACED WATER (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. 1 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:$1024 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:34240017.00 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 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:(y 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 �u 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, 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 constnrct 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 1 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&Wety Code,Sections 25505,25533,and 25534. permit is issued. 1 certify that in the performance of the work for which this permit is issued,I shall Ownerr authorized a nt not employ any person in any manner so as to become subject to the Worker's r Date: �l 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 J P P 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 znify 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 dditio lly le applicant understands and will comply with all non-point s e reg ti s er 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 . . . . . . . . : 34240017 .00 DATE ISSUED. . . . . . . : 11/09/2009 RECEIPT #. . . . . . . . . BS000009144 REFERENCE ID # . . . : 09110040 SITE ADDRESS . . . . . : 22971 LONGDOWN RD SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER HARPER LEROY AND KIM ADDRESS 22971 LONGDOWN RD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2657 RECEIVED FROM . . . . : LEROY D HARPER CONTRACTOR . . . . . . . : MCGEE, PAT LIC # 18986 COMPANY . . . . . . . . . . : WATER HEATERS ONLY ADDRESS . . . . . . . . . . : 970 E MAIN ST CITY/STATE/ZIP . . . : GRASS VALLEY, CA 95945 TELEPHONE (800) 835-5946 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 1, 024 . 00 1 . 00 0 . 00 1. 00 0 .00 1BSEISMICR VALUATION 1, 024 . 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 ----------------- --------------- -------------------- CHECK 110 .50 #1069 --------------- TOTAL RECEIPT 110 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 518 WATER HEATER 0� 1/ 00,gv CITY OF CUPERTINO WATER HEATER PERMIT APPLICATION FORM CUPERTINO APN # 1041)/ t G I 'T Date: 11 1 Building Address: 22c) -7 C- '--) ry � � Owner's Name: Phone #: Z c� � v �J �ePc� X-/c98--86?- S 9/ a Contractor: Phone #: Soo $3 _ �9. Fax #: Cupertino Business License #: Contractor State License #: 189 $ �, 372Y S73 Contact: Sr4 r,,,, 0y �J C -J ro Phone #: 800 -- 83 S- F 9 )(-2-0 -7 Fax #: Building Permit Info: Bldg Elect [ ---- Plumb Mech Residential 13--� Commercial ❑ Solar ❑ If solar, number of kilowatts: Strapped On Platform ❑ Bonded New Location ❑ Replacement Valuation (cost of project): ��J v -2- Project 'ZProject 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: 4�1— Revised 08/20/09 CITY OF CUPERTINO [isWATER HEATER C U P E RT I N O PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Permit Type Grou 1 PCWHEATR Commercial Water B PCWHEATR HeaterNent 1 BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICOM Seismic Commercial B 1 PRWHEATR Residential Water B PRWHEATR --/-------- HeaterNent 1BCBSC 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 y Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 dw OF Fax(408)777-3333 ,;UPEkTINO Building Department JOB ADDRESS: PERMIT # OWNER'S NAME: W Pt i 6 G/-�T,F (��✓ PHONE # app GENERAL CONTRACTOR:C.--.3 c-4—k�A-L FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock T' e er on ctor Signature Date