07100089 CITY OF CUPERTINO �- '`
BU[LDING DI7ISION PERMIT �+��� ��� ��������� *` '
;, ;
...:::....::. __. . _..:
PERMIT NO.
BUILD ����� ss CAROLINE DR FAST W��TER HEATER 07100089 .
PERMIT L55UE DATE
OWNER'S NAME: ,
ZEWELDI REGBE 12601 L32 AVE NE 10 11 2007
SANITARY NO. CONTROL NO.
NE:
BU►LDING PERMITINFO
,aRCHrrecr�NCtxeER: REMOVE �REPLACE GAS WATER B►-�c E�C►' PLUMB MECH
O O 0 Cl
i p p LICENSED COMRACTOR'S DECLARATION TOb DCSCClpt10❑
� v F. I hcrcby afficm that I am licenscd un�icr provisions oC Chaptcr 9(commcncing
; z� with Scction 7000) of Division 3 oC thc Busincss and Profcssiuns Codc. and my liccnse is
�� y in full Corce and effe _
� v� z Licensc Cl s Lic. #
Contraclor
: F' � De � ARCHITEC['S DECLARATION v
i a .�
a i undcrstand my plans shall be used as public records
)yU
° u. F' Licenscd Pmfcssional
� y � OWNER-BUILDER DECLARA'CION
1 hcrchy alTirm ihat 1 am excmp� Crom ihe Conuactor's Liccnsc Law Car U�e
� p O following rcason. (SccGon 7031.5, Busincss and Profcssinns Ca1c: Any ciry or rnunty
�,°, �i which rcquires a permit to conswct, altcr, improvc, dcmalish, or repair any s�+uctmc
�" N prior ui iLS issuancc, also rcquircs ihc applicant for such permi� �o filc a signcd sutc�oem ,. Valuation
� S � that he is licensed pursuan� lo the pmvisions oC the Contracmr's license Law (Chaptcr 9 .>q. Ft. Floor Area
� t— (commcncing with Scction 7000) of Division 3 of Ihc Busincss and Profcssions Cade) or
i�� U�at he is exemp� theicfrom and the basis Car the allcgcd exemption. Any viol�tion o(
Section 7031.5 by a�ry applicant for a permit subjects the applicani to a civil peoa4y of APN Number Oceupancy Type
not moce than five hundred dollars (5500).
❑ I, u owncr af Uie property. or my employces wieh wages as �heir solc compensstioa,
will do thc work, and ihe sttucture is not intended or ofTered forsale (Sec.7044, Busrcsa Required Inspections
and Pro(essions Code: The Conuacmrs License Law docs no[ apply w an awnc of
propeny who builds ar improves thercon. and who daes such work himselt or thmuah 6is
own employccs. provided that such improvemen�s are not imended or ollered for sal� 1[.
however, the building or improvement is sold within one year of compkuon, ihe owoer-
builder will have the burden of proving tAat he did not build or improvc for pmpoce d
salc.).
❑ I. as owner of the property. am exclusively conuacting with Gttnxd convactors b
consnuct �he projett (Sec. 7044. Business and Profcssions Code:) Tl�e Cootracto�s Li-
ccnse Law docs not apply to an owner o( propeny who builds or improves We�ean. aod .
who contracts for s�x6 projeca wiUi a conuactor(s) licensed pursuant to tLe Comnuors
License Law.
❑ I am uempt undu Sec . B& P C for Utia ieZSOn
Owner Datt _ . _
WORKER'S COMPENSAT70N DECLARATION
I hereby aPfirm under penalty of perjury one of the following declazatians
� t hsve and will maiNain a CertiGcatc of Conscnt w self-insure tor Workcrs Compm-
sation, u provided for by Section 3700 of the Labor Code, for the pedoemance o( We
work [or which Ihis permit is issucd.
❑ I havc and will maintain Workcr's Compensa�ion Insunnce, as icyuired by Sectim ,
3700 0( the Labor Codc. Car the performance ot �he worlc for which �his permic is iaued.
My Workers om nsation Insurance c cr Policy numbe aze�: ��
Cartier. � liry No.: ���P__(�
CERTI CATE EXF�v1PIION FROM WORKERS'
COMPENSATION INSURANCE
(This scction irced not be completcd if the permit is for onc hundrcd dotlazs (SI�
ar Icss.)
I ceniCy �hxt in thc perfortnancc of thc work [or which Uiis permit is issucd. ! shall na
employ any person in any manncr so az a bccomc subject w We Worlccrs' Comprnsatian
Laws o( Cali(omia. Da�c
Applicant
NOTICE TO APPLICAM: If, af�cr making this CcrtiCcate of Ezcmption, you shouW
bccome subject to thc Worlcer's Compeacation provisions o( �e Labor Code, you muu
� O forthwith comply with such provisions or this pecmit shall be dccmcd �cvokcd.
z "" CONSTRUCTtON LENDING AGENCY
F r � I hereby alIirm Uwt there is a cons�ructinn Iending agency for the performance of .
�� �hc wurk for which �his permit is issucd (Scc. 3097. Civ. CJ ,
W Q Lendcr's Narnc
� z L.endet's Address
U � 1 certi(Y �hat 1 havc rcad this application and sutc thu Wc a6ovc info�matian is
�� corrcct. 1 agrce �o �omply wi�h all ciry and county oNinances and su�e laws cclating to
C J building conswction, and hercby authoriie representatives of ihis ciry to enter upon thc
, W above-mcn�ioned property (or inspecuon purposes.
a (Wc) agree to save, indcmnify and keep harmless the Ci�y of Cupertino agaiost
H � liabilidu, judgmcnts, wsts and expcnscs which may in any way acciuc agains� said Gty
V z in consequence ot �he granting of �his permit. .,�
�--� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POIKf Issued by Date �� "� �
SOUR LAT[ONS.
— Re-roofs _
� o(ApplicanUConttsctor ° T of Roof
HAZARDOUS MATERIALS DISCLOSURE YP
Will �hc appticant or future building acupant storc or handlc lwardous mamial
as dcfincd by the Cupenino Municipal Codc. Chaptcr 9.12, and the Health and SaCar
c«� Scction 25532(a)? All roofs �hall be inspected prior to any roofing material being installed.
� y� �No _
Will thc applicant or fuwrc building acupant usc eyuipmcn� or dcvicrs which
If a roof i� installed without first obtaining an inspection, I agree to remove
emii harardous air comaminan�t az defined hy the Bay Area Air Quality Managcmeut all new m aterials for inspeerion.
District?
❑ Ycs �Nu
t havc rcad the haTardcws maierials cequiremcn�c uraicr Chap�er 6.95 of thc Califor-
nia Hcalth & Safcry Codc, Scctions 25505, 25533 and 25534.1 undcrstand that iCthc buldin6
docs nol curtenAy have a tcnant, �hat it is my responsibiliry in notify the occupant of the
rcyuircmc Wn�n m� x me� �;o<<o �u��� ara c�Nr�a� aro��a�r. Signature of Appl icant Date
� All roof coverings to be Class "B" or better
O r r authorizcd agcnt
From: 10/10I2007 07:51 �B19 P.004/008
� � � ��� Q j�� 381170
O
CITY OF CIJPERTIl�O
�ATER I�EATER
CUPEI�,TINQ PERMIT A►�'PLI��ATION FORM �
APN# ��� � � /�, O� �: " l (- r7
Building Address:
22059 CAROLINE DR
Owaer's Name: Phone #
ZEWELDI REGBE 408 735-7592
Contractor. Pho� #
FAST WATER HEATER CAMPANY 800-454-8955
G�pertino Business Licxnse # State License #
29100 877489
BuiIding Pamit Info:
_---_
BI 1� ec
Job Descripdon:
Remove/Replace Gas Water Heater
Resideatial g� Cammercial ❑
Cost of Project:
449.00
�
Stiapped On P Bonded
New I�ocatiou � lacement �
QtY• �
A'cable Fee ID FEe Descri 'on Fee ..
� PRVVH�ATR Res idcntial Water Heator /Vent HUII.DING
PCWI�ATR Cvinmer+cial Water HeatedVent BiJII�Il�TG
1 PP�RMTTFEE Piu mbiag Permit Lssusace PLUNIBIN(3
1 TRAVDOC _ Trsvel �k Documentatioa Fee BUII�INCi
BUSLIC Bu;�iness Liccase BITII.IDNG
a
CITY OF CUPERTINO
4 ITEMS OF 12 PERMIZ RECEIPT OPER.ATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ......... 32603015.00
DATE ISSUED.......: 10/11/2007
RECEIPT #.......... BSC00002962
REFERENCE ID # ...: 07100089
SITE ADDRESS ..... 22C59 CAROLINE DR
SUBDIVISION .......
CITY .............. CUFERTINO
IMPACT AREA .......
OWNER ............: ZE�ELDI REGBE
ADDRESS ..........: 22C59 CAROLINE DR
CITY/STATE/ZIP ...: CUF'ERTINO CA, 95014-0106
RECEIVED FROM ....: FW�: ACQUISITION CO
CONTRACTOR .......: JEF'F JORDAN LIC # 29100
COMPAI�TY . . . . . . . . . . : FA:'T WATER HEATER
ADDRESS ..........: 12E01 132 AVE NE
CITY/STATE/ZIP ...: KIF.KLAND, WA 98034
TELEPHONE ........: (8C�0) 454
FEE ID UNIT QUANTITY �,MOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BSEISMICRE VALUATION 449.00 0.50 0.00 0.50 0.00
PPERMITFEE FLAT RATE 1.00 40.79 0.00 40.79 0.00
PRWHEATR LTNITS 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 : 106.56 0.00 106.56 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 319.68 #3334
---------------
TOTAL RECEIPT : 319.68
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER
Community Development
�' � 10300 Torre Avenue
; '�; ' .
��` .� . ;�: Cupertino CA 95014
Telephone (408) 777-3228
CITIf OF Fax (408) 777-3333
�UPEI�TINO
Buildi:n De artment �-� �,00��
JOB ADDRESS: PE�M�
�".
OWNER'S NAME: ' PHONE y -
GENERAL CONTRACTOR: �'G � � ��. F� . � - _! .
I am not using any subcontractors:
Si�;nature Date
Please check a licable subcontractors and com �lete the followin information:
SUBCONTRACTOR BUSIrfESS 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
- !�=l � ����
Owner/Contractor Signature Date