07100132 CITY OF CUPERTINO ' �y ` -p ' 7�.� `
BUILDING'DIV1S10N PERMIT ���� �"�:��'�" �����
. : . ......:.:. .. :
PERMIT NO.
BUIL �r��e�uES�OLBY AVE AFFORDAF LE WATER HEATERS & 0 710 013 2 .
pERMIT L55UE DATE
�R'S NAME:
LEE EDMUND P AND HELEN R 24707 SFN FERNANDO RD � 10/18/2007
SANiTARY NO. CONTROL NO.
P"o"E: ( 6 61) 2 5�— 7131
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
0 0 0 0
i p p LICENSED CONTRACTOR'S DECLARA110N 70b D05Cr1pL10❑
: V� I hcrcby aCfirm that I am licenscd undcr provisions of CAapicr 9(commencing
: z� withSec6on70cx))o(Division3ofiheBusinessandProfcssionsCodc.andmyliccnscis REPLACE 4O GAL GAS WATER HEATER SAME LOC
>> y in full Coree and e C CFct� Z
� v� Z Licensc C acs S� Lic. X
; F � Datc � � - -�
� ARCHiTECI'S DECLAR
j a Q 1 undcrstand my plans shall be used as public rccords
)aU
' u. E' Liccnsed Profcssionat
; � a OW NHR-BUILDER DECLARATION
���
1 hcrcby alTirm ihat 1 am czcmpt Crom thc Conuactors Licrnsc Law far the
j q O (ollowing rason. (Scclion 70315, Busincss and Profacsions Ca1c: Any ciry or rnunty .
�,°, L which requircs a pcanit to conswct, altcr, improvc, dcmal'vch, or ic{wir any unxturc
prior w its issuancc, also rcquircs thc applicant far such permit w fik a signcd s�atcmcnt �' q , Ft. Floor Area Valuation
�?< that he is IiccnscJ pursuant to lhc pmvisions of thc Conuacmr's Licensc Law (Cha(xcr 9 `� �" 13 � �
,� t �(commencing with Scction 7000) of Division 3 of Ihc Busincss and Profcssions Cadc) or
��� thai he is exempt thercfrom snd tAe basu [or the allcgcd eumption. Any violuion of
Secuon 7031.5 by 1�ry applicant tor a petmit subjccu the applicant to a civil penalry of 316 2 8 0 3 ', � Number Oecupancy Type
noc more �an five hundrcd dollars (SS(I0�
❑ I, as owner oC tt�e property. or my cmployces witd wages az Weir salc campenvtion,
wili da thc work and the stcuaum is not intended or ofteced (orsalc (Sa.7044 s�� Required Inspecuons
and Profeuions Code: 'Che Conuactor's License Law docs not apply w an owixr of
� property who builds or improves thereon, and who does such work himselCor Uuougd his
own employces, providcd that such improvements are not intended or olCered Cor sala If.
however, the building or improvement is wld within one year of completion, the owner
buitder will have Uie burden of proving that hc did not build or improve [or pucpose of
sa�.).
❑ 1, as awner of the property, am uclusively conlcacting with licensed conuactnrs a
conswct the p�ojen (Sec. 7044. Business and ProCessions Code:) The Coanactors Li-
ccnse Caw docs not app1Y w an ownu o( propeny who builds or improves �he�eon. and ,
who conuacts Cor such pmjecls with a conuactor(s) licensed pursuant to �he Convauo�s
License Law.
0 1 am ezempt under Sec. . B& P C for Utis reawa
er Daie _.. _
WORKER'S COMPENSA170N DECLARATION
I hercby �rtn under penalry of perjury one of the foUowinB dec�aralions
❑ i h:ve and will maintain a Cutificate of Consent lo self-insuic for Workcrs Compen-
sation, as provided far 6y Section 3700 of the Labor Code, far the pedormancc oC the
work tor which �his pertnit is issucd.
I havc and will maintain Worker's Compensation Insurana, u rcyuired by Section ,
,0 0( thc Labor Cadc, Cw the performancc of Ux work for which this permie is iswed.
,.�y Worker's Campensation Insurance artier and Policy number a�c:� [y
Cartier. ��A1,� � Poliry No.: �! )le� 2S 10 7�l'
CER7'IFICA'Tfi OF EXEMPIION FROM WORKEl2S'
COMPENSATION [NSURANCE
(This section necd not Ac completcd if the pertnit is far onc hundccd dotlazs (5100)
orlcssJ
I ceni(y that in thc perfa�nance of thc work for which ihis permit is issucd 1 shall not
employ any person in any manncr so az w bccomc subjcct to ihe Workcrs' Compensadon
Laws of Califomia Daic
Applicant
NOTICE TO APPC.ICANT: lf, at�cr making this CcniGcate of ExcmpGon, you shoukt
become subjcct to thc Worker's Compensation provisions of We Labor Codc, yau must
� O (oMwilh comply with such provisions or this pecmit shall 6c,dccmcd awokcd.
z "' CONS7RUCTION LENDING AGENCY
(.�-� r�-� I hcm6y �rm Utat thcre is a conswc�ion lcnding agcncy (or thc perCormance af
p�„ � tlu work Cur which ihis permil ia issucd (Scc. 3097, Civ. CJ ,
W Q Lendcr s Namc
� z Lcndtr's Address
(� � 1 certify iha� 1 have read this applicadon and staic that Ure above infomwuon is
w � cortcct. ! agrce �o comply with all city and county oniinanccs and state laws relaang to
� U building conswction, and hcrcby authoriie reprcscniativcs of �his ciiy to cntcr upnn thc
� W alwvc-mcntioncd properry for inspccdon pur�wses.
a (Wc) agrce �o save, indcmni(y and kecp hazmless the City a( Cupertino against
,,,E"' � liabiliues, judgmcn�s, costs and expenscs which may in any way ucmc against said City
U z in conscqucncc ot thc granting at Ihis permit. Da�e
� APPLICAM DERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by.
SOURCE REG ATTONS. �y
�,Q.�" "l. ( d � Re-roofs
Signaturc ApplicanUContractot °ie T of Roof
HAZARDOUS MATERIALS DISCLOSURE YPe
Will lhc applicant or futurc building occupant storc or handlc harardous mucrial
dcfincd by the Cupenino Mumc�p Codc. Ct�ap�cr 9.12. ond the Hcalth and Sa[ety
��. Scction 25532(a)? �/ / All roofs �hall be inspected prior to any roofing material being installed.
❑ Ycs td'�'�o .
wU the applicant or futurc building accupant use equipment or devices whieh .
If a roof i� installed without first obtaining an inspection, I agree to remove
emit harardous air contaminanls az dcGncd by the Bay Area Air Quality Managcmen� all new m aterials for inspection.
�15U���� y /
❑ Ycs �O
t havc rcad the hvardau maierials rcquircmen�s undcrChap�cr6.95 of thc Cali(or- f/'� _����'�
.ia Hcal�h & Sa(cty Codc. ScctioRt 735�5.25533 anJ 25534. f undcrsnnd �hat iCUx huilding � CJ
Joes not curtentty ha a tenan4 �at it is my responsiAility w ndify the occupant o! �he
rcyuircmcn�s which st be me� pcior to issuancc oC a Ccnifuatc of Occupanry. S Lgil3tllI'P� Appl icant Date
�` � All roof coverings to be Class "B" or better
Owncr or a t i�cd agcnt �� -
. U `� i �c� 1 � �
� CITY OF CUPERTINO
� ` ' WATE:� HEATER .
CUPEI�TlNO PERMIT APP:LICATION FORM
Date:
�N# 3 C �� � ��l � a o i� - (�- � �
Building Address:
C� .� �-t� � u � �� � ,q �i E ,
Owner's Name: Phone #:
�� 9 � .� � ,�
���� �. r� �'\ L��_ � 5 C ��_
Contractor: Phon�;: �(e t License #:
ab e v.Te �c,Te �s a 5"� - 1 i 3 � c�a7 � lo�
Contact: Phone.: � b � Cupertino Business License #:
cn� Li � 1 e.F� e t a 5- d� a u �. c� �So
Building Pemut Info:
Bld ❑ Elect � Plumb � Mech �
Job Description:
Residential Commercial ❑
2 aCe y� ' i�o ���5 E� 1'e� - S�n,e � ocarr`n� = C �.� k
Cost of Project:
i3�c
Strapped On Pl�tform Bonded �
New Location � Re lacement �
Qty. if
A licable Fee ID Fee Descri tion Fee Grou
BPWHEATER Water Heater / Vent BUII..DING
✓ � PPERNIITFEE Plumbin Perniit Issuance PLUMBING
i BENERGY Ener BUII.DING
BUSLIC Business License BUII.DING
CITY OF CUPERTINO
4 ITEMS OF 12 PERMIZ RECEIPT OPER.ATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ......... 31E28037.00
DATE ISSUED.......: 10/18/2007
RECEIPT #.........: BSC00003023
REFERENCE ID # ...: 07100132
SITE ADDRESS ..... 10�26 COLBY AVE
SUBDIVISION .......
CITY .............. CUF'ERTINO
IMPACT AREA .......
OWNER ............: LEE; EDMUND P AND HELEN R
ADDRESS ..........: 10�26 COLBY AVE
CITY/STATE/ZIP ...: CUF'ERTINO CA, CA 95014-2420
RECEIVED FROM ....: AFE'ORDABLE WATER
CONTRACTOR .......: LEC�NCE ROUX LIC # 26850
COMPANY ..........: AFFORDABLE WATER HEATERS &
ADDRESS ..........: 24;07 SAN FERNANDO RD
CITY/STATE/ZIP ...: NEVIHALL, CA 91321
TELEPHONE ........: (6E �1)259 - 7131
FEE ID UNIT QUANTITY ��MOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- --•-------- ---------- ---------- ----------
BSEISMICRE VALUATION 1,300.00 0.50 0.00 0.50 0.00
PPERMITFEE FLAT R.ATE 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 : 106.56 0.00 106.56 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 319.68 #3193
---------------
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
CITYOF Fax (408) 777-3333
�UPEt�TINO
Buildin De artment
JOB ADD���� � C � I h I� JQ - PERMIT #
D �lDD/
OWNER'S NAME: � r� �. n L�� PHONE # Dk- 7 d-S- U�E XS
GENERAL CONTRACTOR: � i,,� {+ p. (� FAX #
r � �O85o l ,� _ ,�_ � �
I am not using any subcontractors: �
Si;;nature Date
Please check a licable subcontractors and com �lete the followin information:
SUBCONTIZACTOR BUSIrTESS 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
Owner/Contractor Signature Date