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09080148 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21999 MC CLELLAN RD CONTRACTOR:AFFORDABLE PERMIT NO:09080148 WATER HEATERS & ^WNER'S NAME: TAKASH SATO 24663 RAILROAD AVE DATE ISSUED:08/17/2009 .v'NER'S PHONE: 4089739002 SANTA CLARITA,CA 91321 PHONE NO:(661)259-7131 ❑ LICENSED CONTRACTOR'S DECLARATION G� BUILDING PERMIT INFO: BLDG ELECT PLUMB Lice=Class c 3( i✓ MECH RESIDENTIAL COMMERCIAL Contractor Date a►!w! Z� Date &//9,0 o I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE 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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$1400 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:35713011.00 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 OIF JRERMIT 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 AYS FROM !�T 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 J g. ''7 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. ¢ RE-ROOFS: a:a,ature to 'i /� ©� 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-insu e 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 1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Otjnter or authorized age—. Date: 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 CONSTRUCTION LENDING AGENCY 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 1 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 to building construction,and hereby authorize representatives of this city to enter the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION mify and keep harmless the City of Cupertino against liabilities,judgments, cults,and expenses which may accrue against said City in consequence of the 1 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_ Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 ' UPEkTINO Buildi7(:2:-De artment JOB ADDRESS: �-j Q ,/�i�4 (f t a ll a � PERMIT # OWNER'S NAME: -,rt-"SH PHONE # `6 Y?3 06-2- GENERAL GENERAL CONTRACTOR FAX # -C?-f I am not using any subcontractors: Ir - . --St, ature 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 ,c,fi Roofing ec,'`,-V14I3-r-A)ew Septic Tank Sheet Metal Sheet Rock Tile ontractor Signature Date CITY OF CUPERTINO WATER HEATER CUPEI�TINO PERMIT APP]�ICATION FORM q6�� I � APN # Date: Building Address: Owner's Name: Phone #: Contractor: Phone #: to&I- 1511 - ? 13 1 ff Forcdahte WaW t4eafer1 Fax #: I - Icy - 9SS(, Cupertino Business License #: Contractor State License #: 6 k5D lo�-7 364f Contact: Phone #: (,G - ,�S9- 0 54.a $cofit LittleFielcl Fax #: Building Permit Info: Bldg ❑ Elect ❑ Plumb Mech ❑ Residential Nf Commercial ❑ Job Description: On Platform Bonded New Location ❑ Replacement Strapped �] ❑ Valuation: 1 � pp _ Green Building Check must be completed and attached to this application. Green Building Points achieved: CITE' OI' CUPERTINO - Ari ER IfEArIE.R CITY of CUPEI�TINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Permit Type Group 1PCWHEATR Commercial Water B PCWHEATR HeaterNent BSEISMICOM Seismic Commercial B I 1 PRWHEATR Residential Water B � PRWHEATR HeaterNent J BSEISMICRE Seismic Residential B PPERMITFEE Plumbing Permit P TRAVDOC Travel & B Documentatic n BUSLIC Business License B