07110120 CITY •JF,�UPERTINO �������� ��������r
BUILDING DIVISIdN PERMIT :. <
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PERMIT NO.
BUILDINGA oRBSS: FAST WATER HEATER 07110120
105�0 PINEVILLE AVE '
PERMTf LSSUE DATE
UWNER'S NAME: .
JOHN A. O'CONNOR 12601 132 AVE NE 11/21/2007
SANCCARY NO. CONTROL NO.
PHONE: �800� 454-8955
BUILDING PERMIT INFO
ARCHTIECT/ENGiNEER: BLDG ELECT PLUMB MECH
� 0 � 0
u p � UCENSED CONTRACI'OR oECr.�nxAr�oN Job Description
V ���yy a([�m �ha� 1 am Gxnscd undcr provisions af Chap�cr 9(commencing
�� wiih Sccdon 7000) of Division 3 o(thc Business and Pro(casions Code and my license is REMOVE / RE PLC E GA S WATER HEAT ER
�� y in full force and e[f
� � Z Licensc Clua _ ����� .[ _
� �„ p Dalc — TP
� � � A HTfECI'S DECLARATIO
I undcrstand my plans sAsll be wcd as public recprds
�yU
; W y Liccnsed Professional
� y � OWNER-BUILDER DECLARATION
��rcyy alTinn that 1 am c�ccmpt Crom �he Conuaaor's Liccnsc Law for thc
� O o Collowing rcason. (Scction 7031.5, Busincss and Profc.xsions Cafc: Any ciry or coun�y
y� Pi which mquiccs a pemiit to conswc� altcr. improvc. dcmaltsh. or repair any swcturc
prior to i�s issuancc, alsu tcquims thc applicant for such pertnit to filc a signcd suicment S q . Ft. Floor Area Valuation
—?< that he is licensc d pursuan t to � h c pmvi s i o n s o C � h c C o n u a c t o r' s L i c e n s e L a w ( C h a p i c r 9 $ 4 4 9
Y F� (commcncing with Scction 7000) of Division 3 oC ihc Busincss and Profrssions Codc) or
y�� that he is eumpt Wercfrom and the basis (or the tilegcd exempdon. My violation o[ 7 � Number Occupancy Type
Secuon 7031.5 by airy applicant for a pem�it aubjecu ihe applicant to a civi] penairy of 3 6 913 0:� ��l`J
not more � han f ive 6un d r e d d ollars (5500�
❑ I. u owner o[ the property. or my employces with wages as the'v sole compensatlon.
will do ihe wark. and u�e saucw�e is no� imm�dcd or oft«ed tor sale (Sa. 7044. Bus�ness Required Inspections
and Professions Code: 7'he Conuacwr's License law dces nat ePP�Y a� m9"W of
Propeny q bui�ds or improves iheceon, and who dxs such work himulf or through his
awo pnp►ayees, providcd that sueh improvemenL� are not intended or oRered for sale. l(.
however, the building or improvement ia sold within one year o[ compkuon, ihe owner-
y���der wip have �he burden o[ proving �hat he did not build ar improve [or puryose of
sa1cJ.
❑ I, as owner o[ the property, em e:clusively convacting wilh Gttnaed conuuWrs W
constnut �he pmjea (Sec. 7044. Business and Professions Code:) The Convactors Li-
ccnse Caw does oot apply w an owner of property who builds or improves themon, and .
who convacis tor such projects with a conlractor(s) ticensed pursuant w ihe Convector's
'^ense [.aw.
I am exempt undu See. . B& P C for this icason
Owner Date
WORKER'S COMPENSA770N DECLARATION
I hemby affirtn under penalty of pery'ury �ne of �he following declsrs�ions:
❑ I hsve and will mainuin a Ceni6cale of Consent to xlf-inswe for Workc�s Compen-
sarion, u providcd for by Section 3700 of �he Labor Code, far �he perfarmancc of the
woric for which this pertnit is issued.
❑ I havc and will m�intain Workcfs Compensauon Insurance, u �cquired by Scction ,
3700 of the Labor Codc. Cw thc peRormance of �he work for which �his permit is issued.
My Worker's Compenaation nsunnce ca ' Policy number are:
Gmer: �cy No.:
�F7�p'pg N FROM WO E S' ,
CO ENSATION INSURANC6
(ILis scction necd not bc complcted i[ the permit is for anc hundred dollara (5100) ,
or Icss.)
1 ceniCy that in thc performancc of t6c work [or which this pertni� is issucd. I shall not
employ any pecson in zny manncr so as b bcrnme subjoct to Ufe Worlccrs' Compensation
Laws of Califomia Da�c
Applicant
NOTICE TO APPI.ICAM: If, af�cr making ihis Certificam of ExcmpGon, you should
bccome subject w ihc Worker's Compensation provisions of �hc Lalwr Codc, you muu
, z forthwith comply with such provisions or this permil shall be dcemcd mroked.
z � CONSfRUCf10N LENDING AGENCY
(,,,� � � hcrc6y alLrtn �Mat thcre ia a constnxGon Icnding agcncy Cor thc performancc u(
�„ . ihc work for which �his permit is issucd (Scc. 309'J, Civ. C.) ,
W Q Lendefs Namc
a z Lcnder's Address
I cenify �hat I have tesd Wis application and sia�c ihu �he above in(armation is
w� cortec� I agrce to comply with all ciry md county oniinarces and sute laws mlaung w
0 U building consvuction, and hereby authori�e ccprescnuGvcs of ihis ciry to cntcr upon thc
W aAove-mcntioned property for inspection purposes
� a (Wc) agree to save. indcmni(y and kecp harmless �he Ciry o[ Cupertino against
�„r',� � liabililies, judgmcn�s, costs and expensea which may in any way scc[uc againsl said City ` �7
V z in consequence aC tAc granting o[ �his permiL Date ((� — �� /
►� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-PO1NT Issued by:
SOUR ULA170NS.
- Re-roof : i �/�
o App �cant/Contractor °°'� T of Roof
HAZARDOUS MATERIALS D1SCI,OSURE YPe
Wil! �hc appliant or future building occupant store or handlc ha•rendous matcrial
cfincd by thc Cupenino Municipal Codc. Chaptcr 9.12, md �he Hcalth and Safcty
�� Scction 25532(a)? All roof s shall be inspected prior to any roofing material being installed.
❑ y� �'�I°
�\ If a rooi is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building accupant usc equipment o�Jcvi �which all new materials for inspection.
cmit harardous air contaminan�s u dcfincd by the Bay Arca Air Qualit Mana cmcnt
Disuict?
0 y� �No
� hav� ccad Ihe ha�ardous maicrials requimmcnts undcr Chaprcr 6.95 of dic Califor-
nia Flcalth & Safcry Codc. Sectiaos 23505. 25533 and 25534.1 undcrstand thm iC Ihc building
docs no� curten�y havc s mnan4 ihat it is my rcsponsibiliry w noufy ihc occupant of ihc
myuire n�b m� x�� �o� w�uu� or a c�r�� or o��n��r. Signatu� e of Applicant Date
— - All roof coverings to be Class "B" or better
r or authori�ed agcnt ���
From: 11/06/2�7 14:02 �284 P.003/004
383725
CITY 4F C�UPERTIl�iO �
WATER )HEATER
CUPE(�,TINO PERMIT ,A►PPLI�CATION FORM �� �� . �
�
APN # � Date:
(.� � .�i -� � r�� .
Building Address:
10524 PtNEVILLE AVE
+Owncr's Name: Phone #
OCONNOR JOHN 408 253-0457
Contractor. Phone #
FAST WATER HEATER COMPANY 800-454-8955
Cupertino Business Licxnsc # State Lic�ase #
2s�oa s��as9�
B�ain$ �t r�o:
Bi r�� i, �� M��n
7ob Descripdon:
Remove/Replace Gas Water Heater
Residentia� $] Commercial ❑
Cost of Project: �
4'49.00
Strapped On Platform Bonded
New Loeation � R Iacement �
QtY• � " .
A licabIc Fee ID Fee Descri tian Fee Gmu
� PRWHEATR Resi dcutial Water He.ater /Vent BUII.DING
PCWHEATR Cantmercial Water Heaber/Vent BUII.�ING
1 PP�RMTTI�EE PIuiabing Penanit Issuance PLUiVIB]NG
. 1 TR.AVDOC 'IYa�►e18t I�cumentatioB Fee BUlLDING
BUSLIC Bus:ncss Lic�nse BiT�IDNC3
l S � i S�ri •
CITY OF CUPERTINO
4 ITEMS OF 24 PERMIT RECEIPT OPER.ATOR: SylviaM
COPY # : 3
Sec: Twp: Rng: Sub: Blk: Lot:
APN ......... 3E913030.00
DATE ISSUED.......: 11/21/2007
RECEIPT #.........: B�000003298
REFERENCE ID # ...: 0%110120
SITE ADDRESS .....: 10520 PINEVILLE AVE
SUBDIVISION .......
CITY .............. CL�PERTINO
IMPACT AREA .......
OWNER ............. JCiHN A. O'CONNOR
ADDRESS ..........: 1(�520 PINEVILLE AVE
CITY/STATE/ZIP ...: CifPERTINO CA, CA 95014-4529
RECEIVED FROM ....: F��ST WATER HEATER C
CONTRACTOR .......: JF;FF JORDAN LIC # 29100
COMPANY ..........: F��ST WATER HEATER
ADDRESS ........... 1�;601 132 AVE NE
CITY/STATE/ZIP ...: K==RKLAND, WA 98034
TELEPHONE ........: (f300) 454
FEE ID UNIT QUANTITY AMOUNT 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 UNITS 1.00 24.48 0.00 24.48 0.00
TR.AVDOC FLAT RATE 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