07110123 CITY OF CUPERTINO ` :
su�i�:,,c nr�:�+oN PERNIIT _ G��R���?I� ��1�������
,:: ,: >::.. ,... ....:
- . :. ,:
BUILDING ADDRESS: PERMR NO.
20276 PINNTAGE PY FAST WAI'ER HEATER 07110123 ,
..`VNER'S NAME: ����
GARY & YOUN JEON 12601 132 AVE NE ' 11/21/2007
PHONE: SANiTARY NO. CONTROI. NO.
(800) 454-8955
ARCHI7EC['/ENGINEER: BUIIDING PERMTf INFO
BLDG ELECT PWMB MECH
� � 0 �
u o p LICENSED CONTRAGTOR oEC�nxnnoN Job Description
� I hcreby affirm Ihat I am licenscd umicr provisions of Chaptcr 9(commcncing
� z� with SccGon 7IXw) of Division 3 ot�hc Busincss and Profcssions Codc, and my licensc is REMOVE / RE P LAC E GA S WAT ER HEATER
�� y in full force and ef[
� Z Licensc Class ��• x �
'- ^ p Daic - Conuactar
��,� � ARCHITECI'S DECLAR TI r
� �'� I undcrstand my plans shall hc wed u public rewrda
m�
a
U
L p y Licensed Rufcssionai
y � OWNER-BUILDER DECLARATION
1 hcreby allirm ihat I am excmpt from ihc Can�ractors Liccnsc Law for thc
� < � ra
i p O following reason. (Sccdon 7031.5, Busincss and Profc.csions Ca1c: Any city m rnun�y
K$� which requiccs a permit to conswc4 a�tcr, improvc, dcmolish, or �cpair any suucturc
� Z� prior lo i�s istuancc, alsu mquires ihc applicant for such permit to filc a signeJ sta�men�
�= o that he is liccnscd pucwant to �hc pmvisiona o[ thc Conuactor Liccnse Caw (Chap�cr 9 Sq. Ft. Floor Area $ 4 4 9 Valua[ion
y t- $ (commcncing wilh Scction 7000) of Division 3 af �hc Business and Profcssions Cadc) or
y �., that Ae is exempt therefrom md the basis for the allegcd exempuon. Any violadon of
Scetion 7031.5 by airy applicant for a permit subjecu ihe applicant to a civil penalty of yp Number Oeeupancy Type
not more than five 6undred dollars (5500). 3 6 9 4 7 � 2 7: t� �
❑ i, u owner o[ tlrc prope[ty, ar my employces with wages az the'v sole compenaation,
will do �he work and ihe stnumee is not intended or offeced for salc (Sec. 7044. Businesa Re uired Ins ections
and Pcofessions Cade: Ttie Cnnvactor's License Law does not apply m an owner of �I p
propeny who builds a improves �hereon, and who daes sucA worlc himsel[ or through his
own employces, provided �ha� sixh improvemenu are not imm�ded or ot[ercd for sala I[,
however, the building or improvement ia sotd within one year of compleuon, the owner-
builder will have the burden o[ proving �hat he did no� huild or impmve for puryose of
sale.).
� 1. u awner of the property. sm cxclusively conuacting wi�h licensed rnnusctors to
consvuct 1he project (See. 7044. Business and Ptofessions Code:) The Conttumrs Li-
cense Law docs no� apply w m owner of property who buitds or improves the�eon, and ,
who conUacts for such piojecls wi�h a conlractor(s) Iicensed pursuant w We Convactols
" `^.ense Lsw.
1 am e:empt undu Sec. . B& P C tor �his rcuon
Owur Dale
WORKER'S COMPENSA'C[ON DECLARATION
1 hereby afficm under penalty of perjury one o[ the fallowing decluations:
❑ I hive and wilt mainuin s Cenifinte o! Content to self-insure (or Warkcr's Compen-
sarion, u providcd for by Section 3700 af the Iabor Cade, for the performance o[ thc
work far which Ihis permit is iseued.
❑ I havc and will maintain Workcrs Compensadon ]nsurance, as required 6y Scction
3700 ot thc Labor Code. Cw thc performance of the work for which tAis pertnit is issued.
My Workers om ensa' n lnsunnce cs 'cr d Policy number a�c:
c.m�: or�y Na.: I 7(� /��
RTIFICA F EX ON FROM WORKERS'
COMPENSATION INSURANCE '
(This scction necd not bc eomplctcd if the permit is for anc hundred dollus (S I00)
or Icss.) '
I cenify ihat in thc performance of Wc work (or which �his pertnit is issued, 1 shall not
eTploy any person in any manncr so u w bccome subject to the Workcrs' Compensatlon
Laws of Califomia. Date
Applican� -
NOT7CE TO APPLICAM: !f, aftcr making ihis Ccnilica�c of Exemption, you should
bccome subject to thc Worlcer's Compcnsation provisions of Nc Lalwr Codc, you muu
� O fonhwit6 comply wi�h such provisions or this permit shall bc dccmcd revokcd.
z "' CONSCRUCiION LENDING AGENCY
[-~-� � I hcic6y �rm Uut thcre is a consuucdan Icnding agcncy for �hc perfarmancc of
p�., � ihc work for which �his permit is iuued (Scc. 3097, Civ. C.)
W A Lendcr's Namc '
? � Lcnde�s Address
V 0 [ ceniCY ihe� I havc read this applicuion and siatc that thc above infom�auun is
w� cortcct I agrce w comply with all city and county anfinances and sute Iaws reladng to
0 U building construction, and hercby authorist representativcs of Wis ciiy to cntcr upon Ihc
� w above-mentioncd property for inspenion pmposes
a (We) agree to save, indcmnity and kecp humlesc Ux City of Cupertino against
�F", � liabilitiu, judgmcn�s, cos�c and expenses which may in any way accruc agsins� said Ciry
(� ,'2„' in consequence of thc granung of �his permit. DBLC � -� `
r"'� APPWCANT UNDERSTANDS AND W1LL COMPLY WITH ALL NON-POIM Issued by . — �1' - V�7
SOUR GULATIONS.
- Re-roofs
i ute o(Applicant/Contractor ° a� Type of R oof
� HAZARDOUS MA7'ERIALS DISCLOSURE
Will ihe appliant or fuwrc building acupant storc or handlc ha•rsrdous matcrial
kfined by the Cupertino Municipa] Cadc. Chaptcc 9.12, and thc Hcalth and Safcty
..� Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑ Ycs �70
�11 thc applicant or future building accupant usc equipment or Jcviccs which If a roof i� installed without first obtaining an inspection, I agree to remove
cmit harardaus air contaminan�s u defincd by the Bay Arca Air Quatity Managemen� all new rr aterials for inspection.
Disuia?
❑ Yes �o
1 havc rcad the haiardcws maicrials �cquiremcn�s undcr Chaplcr 6.95 of thc Califor-
nia FlcalU� & Sa(cryCodc, Sections 25505, 25533 a�u125534. I undcrstand �hm iC �hc building
docs not curtently havc a icnan4 ihat it is my responsibiliry �o noufy ihe cecupant nf thc
rcquirc n�s which muu be met �ior w iuuarkc o� a Ccnifuatc o a��r. Signature of Appl icant Date
r rauthariudagcnl p„� All roof coverings to be Class ° B�� or better
CITY OF CUPERTINO
4 ITEMS OF 24 PERMIT RECEIPT OPER.ATOR: SylviaM
COPY # : 3
Sec: Twp: Rng: Sub: B]k: Lot:
APN ......... 3E947027.00
DATE ISSUED.......: 1�/21/2007
RECEIPT #.......... B:;000003298
REFERENCE ID # ...: 0;110123
SITE ADDRESS .....: 2(1276 PINNTAGE PY
SUBDIVISION .......
CITY .............. CtJPERTINO
IMPACT AREA .......
OWNER ............: GE�RY & YOUN JEON
ADDRESS ..........: 2()276 PINNTAGE PKWY
CITY/STATE/ZIP ...: CiJPERTINO CA, CA 95014
RECEIVED FROM ....: Fi�ST WATER HEATER C
CONTRACTOR .......: J]�FF JORDAN LIC # 29100
COMPANY ..........: F��ST WATER HEATER
ADDRESS ........... 1:?601 132 AVE NE
CITY/STATE/ZIP ...: K:�RKLAND, WA 98034
TELEPHONE ........: (�300) 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 R.ATE 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 639.36
---------------
TOTAL RECEIPT : 639.36
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- --------------------
518 WATER HEATER
From: 10/17/�7 13:Z0 �808 P.0051007
~ ' 381885
CITY OF CIJPERTINO
WATER l3EATER
CUPEI�,TINO PEItMIT APPLI��ATION FORM
�v # , D(� n�:
'7 Z �
' � G'�7
B�a� Aaa�:
20276 PINNTAGE PKWY
Owner's Name: Phone #
JEON GARY 8� YOUN 408 309-5974
Contractor. Phoae #
FAST WATER HEATER COMPANY 800-454-8955
Cnpertino Business Liocnse # Sta� Licens� #
29100 877489
Buildi�g Pamit Info: � �
Bld Elect Mech �
7ob Descripdon:
Remove/Replace Gas Water Heater �
Residen ' $j Commercial ❑
Cost of Projec�
449.00
Strapped On Platform Bonded .
New Locatioa � Iacemeut �
� lic�ble Fee ID � Fea Des ''on Fee
q PRWHEATR Raxde�tial WaterHeaterlVeat BUII..DlNG
pCWHBATR Co;ame�ial WaberHea�erNeat BLTII.DING
1 PP�RMPI'FEE PIu.mbing Peimit Issuance PLUMBINC�
� �p� 'IY��vd & Documantation Fee BUII�DING
BUSLIC Bu siaess License BUII.IDNG
1s IG � .