06040122 CITY OF CUPERTINO �),
BUILDING DIVISION PEj MIT iCONTRACT�OR INFORMATIO!I "�..
BUILDING ADDRESS: PLUMB IN TIME INC PERMrr"x'06040122
10656 N BLANEY AV
OWNER'S NAME: PERMIT ISSUE DATE
YEE YEEN WANG 360 MEMORIAL DR STE 140 04/21/2006
ONE: SANITARY NO. COTrlR01.NO.
(866) 293-3031
ARCHff (ENGINEER: BUILDING PERMfi INr-0
BLDG ELECT PLUMB NECTi
too LICENSED CONTRACIDR'S DECLARATION - lob Description
i ux I hcmbY affum ttit 1 am li¢nad uttdcr pmWiou ofCLper 9(mmmvcm9
i<� with Sado,'70W)dDIWam3ddm Budnav and Pmfeahau Cade,aod myL3ameW
REPLACE HOT WATER HEATER 40 GALAS
=m DELL WW77 o.z, Ic .' cI Co A CNrtECIS DECLARATION
I�< Ivndvmad my PWU JWIwuacdup+bod mcorda
-a� L'uatcd Hafutiooal
oma
OWNER-BUILDER DECLARATION
aC 1 wmby allirm rt Ism a1 front the Cnnfcmu nCo LiMy,y o for tic O
❑O rot nt won. cork 7U313.Busirns and Ptd¢+ium Cad.:My dY n rowuy 5 0 0
5$ Mot, mgWma a pmmh re co= t,abcr,impmvc.h p=ij i I Sig any vrunurc
-iy Pnnmiu Wuaac..ofto ma NcapPr..- fn auchprmnt Licc=tadauumtmt
�< thubeullanxJpwvunitalhcprvieiouafthcConha.WriLian¢IAw(CEapm9 Sq.Ft. Floor Area Va [ion
$ (commetWnt with Section 7=of Division 3 of the Buaimu and Pmfnslana Codda
thu he la eaemp tkininfrou,and Ne hula I.ibe aiktd rumptino.MY violation of
Scdmt 70313 by any'appli for a permit aubjecu Ne applicant to a CW Pointy of r Occupancy Type
ora mart thio fine hur4md dollen(SSW). .
❑I,u owoo of Ne ptnpmy,or my nmploysa wirh wato a+think>n*wmPem(lmt,
wl0 do thew Ot,.vd the, .W not W.•.Wd or ffmd for aak(Sa.70 .food—
,0,,
oodau Required Inspections
ad'ndf code The Carua'L km U.doo m apply in w owner d q
pmpotywn,wiMa a Iotpo.ea thcem.ad who dao ntrh wort hlvudfur throuth hu
own'Ownynn,prodded drat such hapo.vanv art rot Ime.dd vaRrrtd for Ne U.
b .Ne Wining n'vcpro.emm in,wld-hhln arc Ser of—Pleilm.the owmo.
bauder.iR ha.<the Woden d pmdnt Jut Ita did not Wild or irry fa Puryoz d
nle.)
p 1,as owtto of the PreP-Y.w oa !v Y canvaaint with Ilaoud cmoamas to
ceamrat the pole,'(Sa.7 .B"inaa ad Prof mical code)The Cmvaoah LL
cmae Law d no,apply to w owner of Propcny who bolds or Impu.ea Nertm,ad'
wbo comncufar surd p*m whine ceatmara)4mied pmmaot 0Ne Com Oi"
Liana(r.
❑Ivo eawpundo See .Bin PCfnthWrraaov
OroQ Dara
WORKERS COMPENSATION DECLARATION
1 bneq afihro Orin,pn by of perjury n or the fdbwint d-'t•^n^^�
❑IN.e ad wtL mainWnaCerdfiae a can,em to vJf.ln,mc for Wn scmnpna.
vtim,N proHdd for by S tin nth d tin I Code,for ds Pofonnua of de
oat Taw Mia P Ooit is=a
❑1 have ad will munuin Walsh Compensation 1w .u irgmred by Satin
37004 the Wo,Code,for tbv prfomtvta time wort for whkh this P kii Lnued.
My Wmtcts Cnnr' m bov.a nim ad Polky.umbv a rt:
C.il.!RWM rC- PalicyNo, !1Y7 Vk9_
_ CEIMFICAIT OF EXEMMON FROM WORKERS'
COMPENSATION INSURANCE ,
Clhis aealat ned rot on cnapimd if Ne pomp Is forme hushed down(SIM)
orib v)
I mdfl thu W WeP farm..Of the wa,k for which Jia P h itnonL 1"Icot
wpioy arty permn in any mu.,to u m bonne abject In the Wort Compotvtim
Im
Of Celiramu Dam
NO CEITO APPLICANT:If.afar mWnt Lids artiflcuc If Eanopim,Ym twuld
Wznm auhjai b Na Wort .Campwtien ptmisoOi atw Law,Coe Yon mus
�O forthwiN comply with such pmvislors n Nu pomp shall bed ind mokd.
Z2 CONSTRUCTION LENDING AGENCY
1 may' > roe work
I.wa h U Wtpint,eW WWaamn(ct 3097.
dCh,.
fa the prrormanad
Da Udei
z nceis Nara
z l< a Addw
U0 I cmifY Nat 1 N.e rod W s appl'vtim ad...v thu Nc ower Wfomudm W
LL '—' ®rm.I attx b cmoply whin all cit,ad county odinuaes ad n.,.Wwi..,;"t m
OU wJdintrnnauuction.ad berchy wNarire npvaenudKa or tnu<irymwavpnn dte
r [C7 abovc.mcntioncd N.Pnny for lupnim P.P.-
to...
uryomato..e.iderairy ad trsp hannlev the Coy of CuPm—atalml
H rA tmbilitio,jdLxnu.cow ad eaprmaa Much may In my way amu.atMmuid Ury
U Z in APPLICANT UNDERSTANDS AND WILL COMPLY WrrH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
a �l�D�tX L1 e� 14 Re-roofs
Sit.vrtc dAppi HAUS MATERIALS DISCLOSURE o.x Type of Roof
WIB Ne aPplkam or tome bWdin'..Pmu pore o,balk haorhro mamrul
u dented by de CVP. oo Mwti iPii]rade.Chia cr 9.11.W the HNth id Safny
Code.Sation 25532407 All roofs shall be inspected prior to any roofing material being installed.
El Y. (__A�Ma
WUI Ne applkun or rmos wildint oaapant= yolpm�i or dc. whkh If a roof is installed without firs[obtaining an inspection,l agree to remove
emit bjt, o air conuinlinw at dc0rrd by tk Bal Am Air owlitY M Cc=m all new materials for inspection.
D.u.n0y. /$1Nu
I hvvcmtl Neth tows matcmla rcqu'vemew undo Cbapter G95 of Ne Uifor
no
Halth 8 Sof6y Code.Sretimi 35505.15533 ad 25531.1 undcrsad thil If the within
dm rot cmmmy
M.•tow,Nu it W my rcepondbUlty to notify IN,aaupw,of de
mrwhrhm'�`rontP.ttoa ,naOfact'=m any. Signature of Applicant Date
�1�a - CYL--"' LI�2 All roof coverings to be Class"B"or better
0.a wNahtl.tent Dvc
r Community Development
10300 Torre Avenue
Cupertino CA 5014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
WUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
i 1JJ �.e -e o66 a Of
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
SUBCONTRACTOR BUSINESS 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
V/ Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
Sm 1 of 2 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 31643022 . 00
DATE ISSUED. . . . . . . : 04/21/2006
RECEIPT # . . . . . . . . . : 34085
REFERENCE ID # . . . : 06040122
SITE ADDRESS . . . . . : 10656 N BLANEY AV
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : YEE YEEN WANG
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-6007
RECEIVED FROM . . . . : PLUMB IN TIME
CONTRACTOR . . . . . . . : PAUL HENDRIXSON LIC # 27607
COMPANY . . . . . . . . . . : PLUMB IN TIME INC
ADDRESS . . . . . . . . . . : 360 MEMORIAL DR STE 140
CITY/STATE/ZIP . . . : CRYSTAL LAKE, IL 60014
TELEPHONE . . . . . . . . : (866) 293-3031
*FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- - --------- ---------- ----------
BENERGY PERMIT FEE 1 . 00 34 . 86 0 . 00 34 . 86 0 . 00
BPWHEATER PER HEATER 1 . 00 10 . 79 0 . 00 10 . 79 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
---------- ----- ----- ---------- ----------
TOTAL PERMIT 84 . 02 0 . 00 84 . 02 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ----------------------------
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
CITY OF CUPERTINO OW40 I (2-2
• WATER HEATER
CUP NO PERMIT APPLICATION FORM
APN V I W^_ W 109 a-- Date:
Buildilpg Address:
Ownef's Name:
Q v
Phone#:
Contr ctor.
Z��6- -025--M-
License
rJ-
License #:
(� . - .
Contact:
Cupertino Business License #
�-� a � '-ems �
Buildii g Permit Into:
Bldg I❑ Elect 114Plumb ] Mech E4,'Job Description: r
r C .
Resid tial Commercial
Cost of Project:
Strapped On Platform Bonded
• New Location.
cation ❑ Re lacement)<
Qty. if
A li able Fee ID Fee Description Fee Grou
BPWHEATER Water Heater/ Vent BUILDING
PPERMITFEE Plumbin Permit Issuance PLUMBING
BENERGY Ener BUILDING
BUSLIC Business License BUILDING
c Iu