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B-2016-1207 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1207 19141 BARNHART AVE CUPERTINO,CA 95014-3500(375 09 045) AFFORDABLE WATER HEATERS&PLUMBING 28358 CONSTELLATION RD STE 698,VALENCIA CA 91.355 OWNER'S NAME: CITU MEI LING DATE ISSUED:01/19/2016 OWNER'S PHONE:408-768-1462 PRONE NO:855-345-9087 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic.#627368 Contractor AFFORDABLE WATER HEATERS&PLUMBING Date X BLDG _ELECT —PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH X RESIDENTIAL—COMMERCIAL with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: REPLACE 40 GALLON WATER HEATER SAME LOCATION OUTSIDE I hereby affirm under penalty of perjury one of the following two declarations: CLOSET 1. 1 have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 2. I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$1800.00 APPLICANT CERTIFICATION certify that I have read this application and state that the above information is correct.I agree to comply with all city and county APN Number: Occupancy Type: ordinances and state laws relating to building construction,and hereby 375 09 045 authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs,and PERMIT EXPIRES IF WORK IS NOT STARTED expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this.permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal 180 DAYS FROM LAST CALLED INSPECTION. Code,Section 9.18. SIssued by: 1444 Signature Date Date: OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed.If a roof is following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for 1. I,as owner of the property,or my employees with wages as their sole inspection. compensation,will do the work,and the structure is not intended or offered for sale(Sec,7044,Business&Professions Code) Signature of Applicant: 2. i,as owner of the property,am exclusively contracting with licensed Date: contractors to construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following..three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1. I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the HAZARDOUS MATERIALS DISCLOSURE performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the 2. 1 have and will maintain Worker's Compensation Insurance,as provided for California Health&Safety Code,Sections 25505,25533,and 25534. I will by Section 3700 of the Labor Code,for the performance of the work for which maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the this permit is issued. Health&Safety Code,Section 25532(a)should I store or handle hazardous 3. I certify that in the performance of the work for which this permit is issued,I material. Additionally,should I use equipment or devices which emit hazardous shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and Worker's Compensation laws of California. If,after making this certificate of the Health&Safety Code,Sections 25505,25533,and 25534. exemption,I become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall Owner or authorized agent: be deemed revoked. Date: APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance correct.I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued(Sec.3097,Civ C.) relating to building construction,and hereby authorize representatives of this city Lender's Name to enter upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address judgments,costs,and expenses which may accrue against said City in ARCHITECT'S DECLARATION consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the I understand my plans shall be used as public records. Cupertino Municipal Code,Section 9.18. Licensed V I I I vrcV 10 1 si.JV (FAX) P.0011002 1 09 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255! Gt)> ERTI[+13 (408)777-3228- FAX(408)777-3333 building(�cupertino.ora misc PLUMBING ❑MECHANICAL ❑ELECTRICAL El MISCELLANEOUS I'.ROIECI'ADDRESS APN{I OWNERNAME - E-MAIL tv STREET ADDRESS crrY,smr E zIP ZW aQ fr-t"1 t-)0 I C FAX Iq 14 1 6 CONTACT NAME - PHONE E-MAIL STREErADDRESSS P CITY,STATE.71P - FAX -. - -Qmotm ❑OWNER OOWNER-DUILDER ❑OWNER AGENT ❑ CONTRACTOR i� .p RACTORAGENT ❑ ARCIIITE•Cf ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTA&E e Water Heaters&piumbin L ENSE R LICENSE TYPE^ LIC# , enc NUMBER 1 BUS. r,, p� COMPANY NAME P' a IOn oad Ste 698 E-MAILValf-MCi.2 -41L t m S -. FAX U[U rn .S lr`P STREET ADDRESS CITY,STATE,ZIP PHONE ft'_ S' g ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL _ .FAX -- STREET ADDRESS- CITY,STATE,ZIP - - PHONE USE OF IKSFDo,DUPLEX ❑ N=Tr-FAMILY PRO1ECTINWILDLAND ❑ YES PROM-Cr IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑.COMMERCIAL URBAN INTERFACE AREA .❑ NO FLOOD ZONE' ❑NO EICHLERHOME? ,❑NO DESCRIPTION OF WORK __•_ 40 Er he af e-r trL2 M 0Cdti0h = 0 _ _._:......__ _...._._ TOTAL VALUATION / I Poo - � i fir. .:srr 0 O By my signature below,I 6rtify to each of the following: 1 am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identified property""for inspection purposes. Signature of Applicant/Agent: Date. ( 1 ,7 � 1 `Y SUPPLEMENTAL INFORMATION REQUIRED E 51 .�. V^ ...::.�._fav�e.��L^'i��._.'.�.;`•�'�.�'._�i'." 5n r:6J`'• a .e —'ar �EfiFi'.:«_�:'r-gn � A1EPMiscApp_201 Ldoc revised 06121/11 PERMIT FEE RECEIPT Case # B-2016-1207 CUPERTINODate Printed: 01/19/2016 CITY OF CUPERTINO FEES RECEIPT Permit Summary Case Number: B-2016-1207 Permit No: Project Valuation: 1800.00 Date Submitted: 01/19/2016 Permit Type: Building Address/APN: 19141 BARNHART AVE CUPERTINO,CA 95014-3500(375 09 045) Receipt#: 200770 Scope of Work: REPLACE 40 GALLON WATER HEATER SAME LOCATION OUTSIDE CLOSET Contacts Contact Type: Applicant Full Name: AFFORDABLE WATER HEATERS& Primary Phone: (661)259-7131 Address: 28372 CONSTELLATION RD VALENCIA,CA 91 Email: permits awhap.com Contact Type: Contractor Full Name: AFFORDABLE WATER HEATERS& Primary Phone: (661)259-7131 Address: 28372 CONSTELLATIONRD VALENCIA,CA 91 Email: ,permits awhap.com Contact Type: Property Owner Full Name: CHU MEI LING Address: 19141 BARNHART AVE CUPERTINO CA 95014 -,01lfr�r Ibn rs\ i . . Plumbing Water Heater Fee $29.00 Strong Motion Category 1 $0.50 Travel and Documentation Fee $48.00 PME Permit Fee $48.00 Bldg Stds Commission Fee $1.00 Plumbing Water Heater Fee 01/19/2016 KATIE VOELTZ Credit Card $29.00 Strong Motion Category 1 01/19/2016 KATIE VOELTZ Credit Card $0.50 Bldg Stds Commission Fee 01/19/2016 KATIE VOELTZ Credit Card $1.00 Travel and Documentation Fee 01/19/2016 KATIE VOELTZ Credit Card $48.00 PME Permit Fee 01/19/2016 KATIE VOELTZ Credit Card $48.00 FEE TOTAL $126.50 AMOUNT PAID $126.50 � o 00 a BALANCE DUE $0.00 t� 1 C i~ d Q Q LL1 O Y CieU V U o ae c p LU ai is a _ o � cnem � ¢� w ~ car 1/1