07100050 CIT�' OF CUPERTINO `> '
BUILDING DI �. �s�o�v PERMIT C�},'�TJ����� I����TI4�N' :
,;<, ;. .:.. ,... _.
: ,;
BUILDING ADDRESS: PERMIT NO.
21366 AMULET DR FAST WA`['ER HEATER 07100050 •
OW NER'S NAIqE: PERMIT LSSUE DATE
YU KOU AND LEE—CHUN 12601 1.32 AVE NE 10 7
NE: SANITqRY NO. CONTROL NO.
(800) 4�4-8955
ARCHITECT/ENGINEER: BUiLDING PERMiT 1NF0
BLDG ELECT PLUMB MECH
� � 0 0
i p p LICENSED CONTRAC7'OR'S DECLARATION JOb DeSCTlpt1011
� V� t hcrcby aCfrm that I am ticcnsed undcr provisions oC ChaQicr 9(commencing
; z� wim SccGon 7000) of Division 3 of thc Busincss and Profcssions Code. and my license is REMOVE /: ZE PLAC E CiA S WATER H EATER
� j y in full Corcc and cf q.
� v� Z Licensc Class L�. �
: F p Dam Contraclor
� ARCHITECI'S DEC ON
i a a i understand my plans shall t�c uscd as p ic rccords
)yU
' u. y Liccnscd Pn�fcuional
� y � OWNER-BUILDER DECLARATION
1 hcrcby alTirm thnt 1 am cxcmpt Crom �hc Comractor's Liccnsc Law for thc
� p O (ollowing rcason. (Scctian 7031.5, Husincss and Profcssions Cak: Any ci�y or county
e,°, Qi which requires a permit to cnnswct. altcr. improvc. dcmolish. or repair any swcture
'? z y pnor ui i1s istuancc, alsu tcquicrs ihc applicant for such permit w filc a signcd statcmeni
-< tha� hc is liccnscd pucsuanl to thc provisions oC thc Contractur's Liccnsc Law (Chap�cr 9 )C�. Ft. F�001' Ar01 Valuation
,� t �(commcncing wi�h Secdon 7000) of Division 3 oC ihc Busincss �nd Profcssions Codc) or $ 4 4 9
i�� tha� he is exempt thciefrom and the basis Cor the allegcd exemptioa Any violation o[
Secdon 7031.5 by a�ry applicant tor a permit subjecu ihe applicant to a civil penalty of Number Oeeupaney Type
nat morc than fivc hundred dollazs (5500). 3 2 6 4 3 0 1���
❑ I, u owncr o( the properry, a my cmployces with wages az their solc compensadon,
will do thc work, and the suucture is rsat intended or o(faed for salc (Sec. 7044. Husiness Re u ired Ins ections
and Pro[essions Cadc: llu Conuactors License Law docc not apply to an owner of Q P
property who builds or improves ttiercon, and who does such wwk himulf or Wough his
own employces. providcd that such improvements are not in�ended or oliered (or sala If,
howevu, the building or improvement is sold wittiin one year of compleuon, the ownv-
builder wiR have the burden oC proving that he did not build or improvc Cor purpose of
sale.).
❑(, u awner of the property, am uclusively conuacting with licensed convactors w
wnsuvct Uie peojett (Sec. 7044. Business and ProCessions Code:) The Contraccor's Li-
ccnse Law docs not apply �o an owncr of propeny who builds or impmves thneon, and ,
who conuacts Co� such projects with a contnctar(s) liansed pursuant to �he Convactor's
License Law.
❑ I am exempt under Sec. , B& P C for this �cason
Owner Date _ .. _
WORKER'S COMPENSAI'ION DECLARAI'lON
I hereby affirm under penalty ot perjury onc of the following declarations:
❑] hsve and will main�ain a Certificate of Consem to self-insure for Workcr's Compen-
sation, as provided for by Section 3700 oC the [abor Code, far �he pertormance af ihe
work for which this permit is issucd.
❑ I have and will maintain Worker's Compensation (nsunnce, as required by Scction
3700 0[ thc Labor Codc, for �hc perfarmance of the work (or which �his permit is issued.
My Worke�s Comp nsauon lnsumnce c�'cr d Policy num are: /'
Cartier. oticy No.: �/ ��/�/ n�
C?RTIF[CATE F XEMP'C10N FROM WORKERS'
CO PENSATION INSURANCE
(This scction necd not be complctcJ if the permit is for onc hundred dollazs (5100)
or Icss.) '
I certify tl�at in the perfortnance of Ihe work for which ihis permit is issucd. [ shatl not
employ any person in any manncr so u w beeomc subject ta the Workcrs' Compcnsation
Laws of Califomia. Datc
Applican�
NOTICE TO APPLICAM: If, aftcr making ihis CcniGca�c o( Excmption, you shoulJ
bccome subjcct lo �hc Workcr's Compcnsation provisions of ihc La6or Codc. you must
� O fonhwi�h comply with such provisions or this permit shall be dcemed cevoked.
z '"" CONSTRUCf10N LENDING AGENCY
( r I herehy aCfirm Wat there is a conswction tending agency Cor the perCormancc uf _
a., � thc work for which ihis pcmiit is issucd (Sec. 3091, Civ. CJ
W� A Lendcr's Namc '
a � Lcnder's Address
(� � t cenify that I havc rcad Uiis application and siatc that thc abovc infortnapun is
w ►" cortcc� I agree �o comply with all city and county onlinanc�s and sute Iaws relaang to
0 U building conswction, and hcreby authori�e represcnutivcs of ihis city �o cntcr upon tAc
� W abovc-mcntioncd propccty for inspccUOn purposea.
�y (We) agree to save, indcmai(y and kccp harmless ihe City o( Cupcnino against
�� liabilities, judgmcn�s, costs and expenses which may in any way accruc agains� said City
V z in consequence oC the granting of ihis permi� Date �
►+ APPLI M UNDERSTANDS AND WILL COMPLY W17'H ALL NON-POINT Issued by: f �
SOU ATIONS.
�"' Re-roofs
n rn� uco��«o� ° atc Type of Roof ��
HAZARDOUS MATERIALS D[SCLOSURE
wll � applieant or future building occupantstorc or handle harardous matcrial
u defincd by Ihe Cupenino Municipal Codc. Chap�cr 9.12. and the Health and Sa(cty
Calc, Scction 25532(a)? � All roofs ;>hall be inspected prior to any roofing material being installed.
oY� �� ,
Will �he applican� or future 6uilding accupant use eyuipment or devices which
If a roof i;� installed without first obtaining an inspection, I agree to remove
cmit haiardous air conuminan�t as dcfincd Ay the Bay Arca Air Quali�y Managcmcnt all new m aterials for inspecrion.
nisaict?
❑Ycs Nu
1 havc rca�i ihe ha�ardous matcrials rcquircmcn�s undcrChap�cr6.95 of Uic Califor-
nia HcalU� & Safcty Co�, Scctions 25505, 25533 and 25534.1 undcrstand �hat i(thc building
docs not cu nUy havc a Icnant, 1ha[ it is my rcsponsibility W noaly thc occupant of Ihc
rcyuirc m� x�� P�a� a�u��� or a c��r�a� or a����r. S ignature of Appl icant Date
p �� . All roof coverings to be Class "B" or better
aulhorizcd agcnl
From: 10I04/�007 15:13 �493 P.OD3/008
' 388140
�7/�� C�� C�
CITY �F C�I7�'ERTI�iO
�ATER ��EATER
CUPEI�„TINO PERMIT A►PPLIt;ATIUN FORM
APN # �v� C.O � O` • O v Daoe: j 5.. G`
Buildiag A@diess:
2'1366 AMULET DR
Qwne�c's Name: - Phone #
YU KOU 408 773-1608
Comtractor. Phone #
FAST WATER HEATER COMPANY 800-454-8955
Cupertino Busiaess License # State Licease #
29100 877489
Bu;�lcting Permit Info:
_-�
Bl lum Me'
Iob Description:
Remove/Replace Gas Water Heater �
Resid�n ' g] Commercial ❑
Cost of Pr�jcct:
449.00
Strapped On Platform Boaded
New Lflcation � Iacement �
QtY• �
A licable Fee ID Fe� Descri 'on Fee
� PRWHEATR Resic le�ntial Watcr �Icater Nent BiJ1LDING
PCWHEATR ComnGC+ciai WatarHaaber/Vent BUII,DING
1 PP�RMITFEE PIumbing Permit Isstiance PLUMBIlVC3
1 TRAVDOC Trav�:l dt Documentation Fee BUII.DING
BUSLIC $usv �e.ss License BUILIDNG
. �
CITY OF CUPERTINO
3 ITEMS OF 6 PERMI`� RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Bl:c: Lot:
APN ......... 32�i43019.00
DATE ISSUED.......: 10�05/2007
RECEIPT #.......... BS�)00002899
REFERENCE ID # ...: 07:L00050
SITE ADDRESS .....: 21:366 AMULET DR
SUBDIVISION .......
CITY .............. CU:?ERTINO
IMPACT AREA .......
OWNER ............: YU KOU AND LEE-CHUN
ADDRESS .... ....... 21:366 AMLTLET DR
CITY/STATE/ZIP ...: CU:?ERTINO CA, 95014-1301
RECEIVED FROM ....: FW]i ACQUISTION CO
CONTR.ACTOR .......: JE:?F JORDAN LIC # 29100
COMPANY ..........: FA�3T WATER HEATER
ADDRESS ........... 12i01 132 AVE NE
CITY/STATE/ZIP ...: KI:ZKLAND, WA 98034
TELEPHONE ........: (8)0) 454
FEE ID UNIT QUANTITY .�'IOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
PPERMITFEE FLAT RATE 1.00 40.79 0.00 40.79 0.00
PRWHEATR UNITS 1.00 24.48 0.00 24.48 0.00
TR.AVDOC FLAT R.ATE 1.00 40.79 0.00 40.79 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT : 106.06 0.00 106.06 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 212.12 #3333
---------------
TOTAL RECEIPT : 212.12
�-W "',,
Community Development
r .' 10300 Torre Avenue
"' . � �;s; ,' Cupertino CA 95014
yr
Telephone (408) '177-3228
CITY OF Fax (408) 777-3333
�'UPE�,TINO
Buildin De artment
JOB�DDRESS: PERMIT #
� � � �����
OWNER'S NAME: PHONE # _
GENERAL CONTRAC R: f FAX #
I am not using any subcontractors:
Si;;nature Date
Please check a licable subcontractors and com �lete the followin information:
SUBCONTRACTOR BUSIrIESS 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
Tile
_ �(� �C� s'—�? _
er/Contractor Signature Date