07100133 CIT�' OF CUPERTINO ' ' `
BUILDiNG l7�VIS10N PERMIT ��.l�k�►.��C?�. ������TI�N :
, ,,:. ,,.
<::� ._
BUIL PERMIT NO.
��� DR AFFORDABLE WATER HEATERS & 07100133 .
ER'S NAME: PERMIT LSSUE DATE
R.ACHEL FRIEDMAN 24707 S?�11 FERNANDO RD 10/18/2007
PHONE: SANITARY NO. CONTROL NO.
(661)259-7131
ARCHI'IECl7ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMH MECH
� � 0 �
i p o LICENSED CON7RACTOR'S DECLARA7'iON JOU DeSCTlp$OIl
%� ! hcrcby afGrm that I am licenscd unckr provisions af Chaptcr 9(commencing
: Z � wi�h Scction 7o00) af Division 3 of ihc Busincss and Prafcssions Cadc and my Iicensc u RE PLAC E WATER HEATER
�� y in full forec and cllec[. /r 3/_ �
��? Licensc Class �� L� Lic. ii '
: y � Datc ► b- 1 -� 7 Conuactnr
ARCHiTECI'S DECLAR ON
Z a a 1 undcrstand my plans shall bc uuJ as public rernrds
>dv
' u. F' Licensed Prufcssional
� y � OWNER-BUILDER DECLARATION
i hcrcby alTirm that I am excmpt Crom thc Contractor's Liccnsc Law far ttie
� p O (ollowing reason. (Scctian 703I.5, Busincss and Profcssiaas Caic: Any city or couuy
�,°, �i which rcquires a permit to consUUCt, altcr, impmve, dcmolish, or repair any unoctmc
� Z � prior ui i�s issuancc, alsu requires �hc applicant for such permit to filc a signcd s�a�rmmt
e �hat hc is liccnscd pursuan� lo thc provisions of ihc Conuxtur's Liccnsc Law (QiaMcr9 3q. Ft. Floor Area $16 O O Valuation
r t s - �(commencing wiih Scction 7000) of Division 3 af ihc Business and Profcssions Cade) nr
L�� that he is exempt �he+cfrom and t6e basis !or the allcgcd exemption. Any violatioa a[
SecUon 7031.5 by arry applicant Cor a petmit subjccu the applicant to a civil pa�alry of 3 6 9 3 9 0 2 8�D� Number Occupancy Type
na more than five hundred dollars (5500).
❑ I, as owncr o[ tt�e pcopercy. or my cmployces with wages as �he'v solc compensuiaa.
wiil do thc wor!c, and the suucwm is not intcndcd or uRered [or sale (Sec. 7044. Busness Re u ired lns CCt10 i1S
and Professions Cade: The Conuactor's L.icense Law dacs not apply to sn owner d 9 p
property who builds or improves thercon, and who daes such wort himselCar ihcouah his
own employces, providcd that such improvemenLS are not imended or o[fered Cor ale. I[,
however, the building or improvement is sold within one year oC complcdon, iRe oaoer-
builder will have We burden of proving �hat he did not build or improvc tor pu�pox d
salc.).
❑ I, as awner of the property, am exclusivtly conlracting with littnsed rnntrxlars �o
constmct �he pcojm (Sec. 7044. Business and ProCessions Code:)'Ihe Contrxtars Li-
cense Law does oot apply to an owncr o( propeny who builds or improves WeROn. aad . _,
who contracts [or such pmjecLt with a con�ractor(s) licenxd pursuanl to ihe Convactors
License I.aw.
❑ 1 am ezempt under Sec . B& P C for this �
,er Date _.. _
WORKERS COMPE.NSATION DECLARATION
1 hereby �rm under penalty o[ pe�jury one of the fotlowing declaratiart�
❑ i h:ve and will mainuin a CeniCcate of Consenl lo sel(-insurc far Workers Campra-
sation, u providcd for by Section 3700 of the Labor Code, for the performa�xe ot the
work for which Ihis permit is issucd.
� havc and will maintain Workcr's Compensation Insurance, as �cquired 6y Seetion
J of ihc Labor Co�. Cor the per(ortnancc of We work for which U�is pertnit is issaed.
,.�y Worke�s Compensa Insurance cacrier and Poliry n / azc: Qy
Cartier. f� V1' PolityNo.: LO1���-rO �r�—
�CERTIFICATE OF EXEMPT[ON FROM WORKERS'
COMPENSATIONINSURANCE
(This section need not be completed if the pertnit is [orane hundrcd dollazs (5100)
or IcssJ '
I ceni[y th�i in dtc performancc of thc work for which Ihis permit is issucd [ s6aI1 not
employ any person in any manncr w as to bccomc wbject to �he Workcrs' Compensation
Laws of Califomia. Datc
Applicant
NOTICE TO APPLICAM: 1f, af�cr making �his Ccrtiticate of Ezcmp�ion, you shouW
become subject to �Ae Worker's Compensation provisions of the Labor Code, yau must
, O forthwith comply with such provisions or this permit shall bc dccmcd icvokcd.
z '"" CONS7RUCIlON LENDING AGENCY
E r.�-+ I hcicAy a�rtn Uiat thcro is x construction Icnding agc�y Cor thc perfortnarcc of ,
GYi � thc wurk fur which this perniit is iuucd (Scn. 3097. Civ. CJ
W Q Lendcr's Narnc '
� z L,cnder's Address
V � 1 certify that 1 havc rcad this application and sia�c tha� thc above in[amatiun is
� �--� cortcct. I agree to comply wi�h all city and county oreiinances and sute laws relating m
0 U building conswciion, and hereby authoriie reprcsentatives of Ihis city to entec uptm �hc
� W abovc-mcntioncd property for inspccuon purposes.
a (Wc) agrce to save, indcmnify and kecp harmleu thc City of Cupcnino againtt
H � liabilitia, judgmcnts, costs and expenscs which may in any way acccuc against said Gry
V z in conscqucncc of thc granting of Ihis permit. Date
� APPLICANT UNDERS7ANDS AND W1LL COMPLY WITH ALL NON-POIPII' Issued by
SOURCEREGU ONS.
t R'�1 � �-' ��-- �9 � Re-roofs
Signawrco(A icanUContractor � T ofRoof
HAZARDOUS MATERIALS DISCLOSURE }��
Wilt �he applicant or futwc building occupantstorc or handlc harardous ma/enal
dcfincd by the Cupertino Municipal Codc. Chaplcr 9.12. and thc Hcalth and SaCeq
Ic. Scction 25532(a)? �� All roofs �hall be inspected prior to any roofing material being installed.
0 Ycs ` _ .
Will thc applicant or (uturc building occupant usc eyuipmcnt or dcviccs whie6
If a roof i� installed without first obtaining an inspection, I agree to remove
cmii harardous air comaminants az Jefincd 6y thc Bay Area Air Quality Managcment all new m aterials for inspecr.ion.
Disvict?
Q Ycs o
1 havc rcad the ha�ardrnu maicrials requircmcn�s undcrChaplcr 6.95 of lhc CaliCoo- G
Hcalih&SafctyCadc,Sccuons25505,25533arul25534.Iundcrstv�dthazitihc6uildinb � � �O � (O ��,��
uocs not curtcntly ha a �cnan4 �1+at it is my responsibility w noufy thc accupaat a( �he
myuircmcn�swhich �bcmetpri <<�;���uorac�r�a�ara�uP��. Signature, Applicant Date
- ✓ v All roof coverings to be Class "B" or better
Owncr or aut r' agcn� ���
� CITY OF CUPERTINO
` WATER HEATER
CUPEt�,TINO PERMIT APPLICATION FORM p`�/ D0/33
APN # � 3Gf .. ��,g Date:
o � �9 <<�-rd�-o�
Building Address: , , -.
- ��^ ��, c i� �� c. 1� c .
Owner's Name: . Phone #: L , , � �
��5���� �� f ��-��r'�c:� (G��- �f�re� IS � �
Contractor: Phon �: �(� t License #:
ab e a1e eaTe�s a5��i - 7�3 1 c��-7 310�'
Contact: Phonf;: l� b � Cupertino Business License #:
cn� Li �r � e,F� e 1 a 5- o� a u ���Su
Building Pemut Info:
Bld ❑ Elect L'�1_ Plumb � Mech C�---
Job Description:
Residential Commercial ❑ .
2 aCQ �� ' ilo �'�.S ('ln1�e� - Sun,e � CC�ri br� = Ir�1 c�� � � C l�SE -i
Cost of Project: �' � I �, i I ��-' �, y)
I �. �� �-� .
Strapped On Platform ❑ Bonded �
New Location � Re lacement �
Qty. if
A licable Fee ID Fee Descri tion Fee Grou
9 BPWHEATER Water Heater / Vent BUII.DING
PPERMTTFEE Plumbin Perniit Issuance PLUMBING
/ BENERGY Ener BUII.DING
BUSLIC Business License BUII.DING
CITY OF CUPERTINO
4 ITEMS OF 12 PERMI`�' RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Bl]�: Lot:
APN ......... 36'�39028.00
DATE ISSUED.......: 10,'18/2007
RECEIPT #.........: BS�)00003023
REFERENCE ID # ...: 07:_00133
SITE ADDRESS .....: 20:?60 PACIFICA DR
SUBDIVISION .......
CITY .............. CU:?ERTINO
IMPACT AREA .......
OVJNER ............. R.Ac;HEL FRIEDMAN
ADDRESS ...........
CITY/STATE/ZIP ...: ,
RECEIVED FROM ....: AF]?ORDABLE WATER
CONTRACTOR .......: LEc)NCE ROUX LIC # 26850
COMPANY ..........: AF:�ORDABLE WATER HEATERS &
ADDRESS ..........: 24'107 SAN FERNANDO RD
CITY/STATE/ZIP ...: NE[VHALL, CA 91321
TELEPHONE ...... (6�i1)259
FEE ID UNIT QUANTITY ��'IOUNT PD—TO—DT THIS REC NEW BAL
---------- ------------- ---------- —--------- ---------- ---------- ----------
BSEISMICRE VALUATION 1,600.00 0.50 0.00 0.50 0.00
PPERMITFEE FLAT R.ATE 1.00 40.79 0.00 40.79 0.00
PRWHEATR ITNITS 1.00 24.48 0.00 24.48 0.00
TRAVDOC FLAT R.ATE 1.00 40.79 0.00 40.79 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT : 106.56 0.00 106.56 0.00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER
�w�` Community Development
� 10300 Torre Avenue
�' ' �.� ' Cupertino CA 95014
�.�
Telephone (408) 777-3228
CITY OF Fax (408) 777-3333
CUPE�TINO
Buildin De artment
ao��o D � - �� c � " PERMIT #
� � ► i � '� r _ D �I�0D�33
OWNER'S NAME: �U S Q� F c' i�. rtic•,,• PHONE # 0�- �{ 4 6- i�
GENERAL CONTRACTOR: �y.�. t,J � A(' FAX #
a�g�
I am not using any subcontractors: C,� � 1 p���_[� ��
Si gnature Date
Please check a licable subcontractors and com lete the followin information:
SUBCONTRACTOR BUSIPJESS NAME SUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linolewn / 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