07100022 CIT�' OF CUPERTINO ` ' (`� ` " `
BUILDiNG DIVTSION PERMIT ���� *�'�Q������`��
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BUILD �,��Br�essBAYW00D DR BETTER WATER HEATERS P 0 710 0 0 2 2 .
OW NER'S NAME: PERMIT LSSUE DATE
LILLIBRIDGE ED W AND CAROL 351 FALCATO DR � 10/02/2007
lE; SANITARY NO. CONTROL NO.
(408)250-6672
ARCHITECT/ENGiNEER: BU(LDING PERMiTINFO
HLDG ELECT PLUMB MECH
�� � 0 �
i p p LICENSED CON'I'RACfOR'S DECLARATION JOb DeSCiIpU0i1
% w� 1 hcrcby aCGrm Wat I am liccnscd undcr pravisions of Chaptcr 9(commcncing
; z� with Section 7000) of Division 3 of ihc Busincss and Profcssions Codc, and my liccnsc is * N� C 0[VD I T I ON S ' r / /� ` � j ���
� a a � full farce and efCec� G� L�� /�(-� G t
j � ? Licenx Class �• # � .
; f ;, w Datc Conuacwr
� ARCHITECI'S DECLARATION
i a� t undcrstand my plans shall hc uscd as public rcrnrcLs
)yU
' � y Licensed Pcu(cssional
� y � OWNER-BUILDER DECLARATION
1 hcreby alTirm thal 1 am exempt Crom �hc Caniractor's Ucensc Law Car U�c
� p O Collowing raasan. (Section 7031.5, Busincss and Profcssions Calc: Any eity or munty
�,°, �i which requires a pc�mit to conuruct, altcr. impmvc, dcmalixh, or repair any swaurc
° z� prior to ils issuancc, alsu tcquires Uic applicant Cor such pertnit to filc a signcd su�emcnt �,
- that hc is liccnscd pursuant to thc pmvisions o[ Uu Comractor's Liccnsc Law (Chaptcr 9 ,� Ft. Floor Area $ 8 O O Valuation
r t �(commcncing wi�h Section 7000) of Division 3 of �hc Busincss and Profcssions Codc) or
y�� �hat he is exempt thcccfrom and the bazis Cor the alleged exempdon. Any violation oC
Stction 7031.5 by arry applicant Cw a permit subjecu ihe applicant w a civil penalty of 316 3 0 017A� Number Oeeupaney Type
not more Wan fivc hundred dollazs (5500). •
❑ I, as owncr o( ttie propecty, a my cmployca with wagu az their solc compensadon,
will da thc work and the stcuctum is not intendcd or ollered (or sale (Sec. 7044. Business Re uirzd Ins ections
and Professions Cadc: The Conuacwr's Licenu law dacs not apply tn an owner of Q �
propeny who builds or improves �hercon, and who does such worlc himselCor Uuough his
own emQloyccs. providcd tha� such improvemenu are not in�ended or o[ferod (or sala [f,
howevu, the building or improvement ia sold within one year oC compledon, ihe ownu-
buiider will have the burden ot pmving that he did not buiW or imprave fo� purpoxe o[
sa1cJ.
❑ 1, as owner o[ the propeny, am ezclusively conuacting with Iimnsed contractnrs W
conswct che projen (Sec. 7044. Business aod Professians Code:) The Coatrxtars Li-
cenu Law dacs aot apply to an owner of property who builds or improvrs tdeieon, and ,
who rnnlracts for such pmjects wilh a conlnctar(s) liansed pursuant to U�e Cnntractofs
License Law.
❑ I am ae r Sec , 8� f this reasoa
Owner � V �� "v � Da�e � .. --
WORKER'S �PEN N DECLARA'110N -
I hcrc6y afficm under penalty of perjury rn�c of the following declazuions:
,� i hsve and wilt maimain a Cenifiqtc of Consent to sclf-iasurc for Worker's Compen-
satian, as providcd for by Sation 3700 ot the La6or Code. (ar �he performancc of tLe
work for which Ihis pertnit is issued.
❑ I have and will maintain Worker's Compensauon Insurance, u tcquired by Scction
3700 0( the Labor Code, Cor the performance of the work (or which this permit is issued.
My Worke�s Compensation Insurance carticr and Poliry num6cr azc:
Cartiu: Policy Na.:
CERTIFICATE OF EXEMP170N FROM WORKERS'
COMPENSATION iNSURANCE
(iAis scctian necd not be completcd if the permit is for onc hundred dollazs (5100)
nr less.) '
I cenify thzt in thc performancc of �hc work (or which lhis pertnit is issucd. [ shall not .
employ any person in any ncr u a c c wbj t io Worlccrs' Compensa�ian
Laws of C Da�c
Applican� � �
NOTICE TO APPLICAM: , r m ing ihis Ceru icatc of ExcmpGon, you shoulJ
bccome subjcct w thc Workcr's Compcnsadoa provisions of thc La6or Codc, you must
� O fonhwi�h comply with such provisions or this pccmi� shall bc dccmcd mvokcd.
� ''' CONSTRUCTION LENDWG AGENCY
(� ��-+ I hcreby afGrtn ihat there is a cons�rucuon Icnding agcncy for thc per(ortnance of
�Yi � the work for which this pertnit is issued (Sec. 3097, Civ. CJ
W� Q L,endcr's Namc '
� � (,cnder's Addrcss
V � [ certifY lhal I havc rcad this application and sta� ihat thc abovc infocmatiun is
w� cortcct. ! agree to comply with all city and county oNinances and s�ate laws reladng to
.J J 6uilding conswction, and hcreby authome represcnta�ivcs of this ci�y to cntcr u�n �hc
W abovc-mcntioncd property for i�specuon puriwses.
(Wc) agree to save, indcmnity and kecp hartnless �he City of Cupcnino against
E � liabilides, judgmcnts, costs and ezpcnscs which may in any way accruc against said City
(� z in consequcncc ot �c granting o[ ihis permit. Date
*� APPL1CANf UNDERSTANDS AND WILL COMPLY TH ALL NON-POINT IsSUea by: •— Z�
S GU ONS.
� � Re-roofs �,��/
Signaturc of App ' Co to ; Dale Ty�C Of R� )Of
HAZARDOUS MATERIALS DISCLOSURE
Will �hc applicant or Cuwrc building occupantstorc o� handlc ha•rardous maicrial
u dcfincd by the Cupertino Municipal Codc, Ct�aptcr 9.12, and the Hcalth and Satcty
Codc. Section 25532(a)? All roofs : hall be inspected prior to any roofing material being installed.
�y� ❑No
Will �hc applicant or futurc building occupant usc eyuipmcnt or dcvices which If a roof i: installed without first obtaining an inspection, I agree to remove -
mii harardous air contaminants u dcfincd by �he Bay Arca Air Qualiry Managcmcnt all new m; iterials for inspection.
Disvict?
❑ Ycs ❑ No
1 havc reu1 the ha�ardcws maierials rcquircmen�s undcr Chap�cr6.95 o(thc Califorv
nia Hcalth & Safcty Codc, Scctions 25505, 25533 and 25534.1 undcrs�and ihaz i( ihc building
docs no� urtcmly havc a tcnan4 �� �� is my mspoasibility w noufy thc occupant nf ihc
rc must bc met prior u� issuancc of a Ccnifica� f •�� Signature �f Applicant '„ Date
oW���o�a�mo���.�aaE��� „� All roof coverings to be Class � B or better
CITY OF CUPERTINO
\ r � � � ������
�'VA'I'EI� I�Et-�TER
�uPE�,T�NO PERMIT APPI.ICATION FORM
APN # � ) �� Dat • e
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Building Address: L
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Owner'�N e: \ � � Phone #
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�C � `--�\ � �'� '. �c. �� � _ 1 i -- I
Contractor• Phone #
� � �=� ��.. r-' �. �� � � � �
Cupertino Business L'cense # � �`�, tate License #
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Building Pernut Info:
Bld Elect � Me�
Job Description:
��=�. �,..C.� �.� �., c" =� r --
Residential Commercial ❑
Cost of Project:
� o �� �
��
Strapped On P tform Bonded C
New Location � Re lacement�
Qty. if
A licable Fee ID Fee Descri tion Fee Grou
PRWHEATR lzesidential Water Heater /Vent BUII.DING
PCWHEATR l�ommercial Water Heater/Vent BUILDING
PPERMITFEE l'lumbina Pernut Issuance PLUMBING
� TRAVDOC 'Cravel & Documentation Fee BUII.DING
BUSLIC :3usiness License BUII.IDNG
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIZ RECEIPT OPERATOR: suew
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 31630017.00
DATE ISSUED.......: 10/02/2007
RECEIPT #••..•••••: BS000002862
REFERENCE ID # ..-: 07100022
SITE ADDRESS .....: 19905 BAYWOOD DR
SUBDIVISION .......
CITY .............: CUFERTINO
IMPACT AREA .......
OWNER ............: LILLIBRIDGE ED W AND CAROL
ADDRESS ...........
CITY/STATE/ZIP ...: ,
RECEIVED FROM ....: EDWARD LILLIBRIDGE
CONTRACTOR .......: FRANS CARTWRIGHT LIC # 26514
COMPANY ..........: BEZTER WATER HEATERS
ADDRESS ..........: 351 FALCATO DR
CITY/STATE/ZIP ...: MILIPITAS, CA 95035
TELEPHONE ........: (408)250-6672
FEE ID UNIT QUANTITY P.MOUNT 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
TRAVDOC FLAT RATE 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
----------------- --------------- --------------------
CREDIT CARD 106.06 MC
---------------
TOTAL RECEIPT : 106.06
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
Community Development
`� w � 10300 Torre Avenue
a�:�
�' ..E�° Cupertino CA 95014
__..
Telephone (408) 777-3228
CITY OF Fax (408) 777-3333
':UPEI�TINO
Buildin De artment
JOB ADDRESS: PERMIT #
1"'� O�j � �J�� I�Z�V � ��.e�a��,3�,, `��b�� l� �7 �UU ZZ�
OWNER'S NAME: 'C�'� �.,, � � 1 PHONE # " � —� �
GENERAL CONTRACTO : FAX #
a
I am not using any subcontractors: °� � r - R � s �' ��
' Da't'e �
Si;;nature ��� ��
Please check a licable subcontractors and com �lete the followin information
SUBCONTRACTOR BUSIrTESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
IIectrical
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
�
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Owner/ Contractor Signature ate '