06020098 CITY OF CUPERTINO ' xAsa 1 ;-5 ''
BUILDING DIVISION PERMIT �+CONTRACTOR INFORMATIQN ,s:
BUILDLNGADDRF : WATER HEATERS ONLY �mn'NO-06020098
10180 BYERLY CT
OWNERS NAME: PFRhffr ISSUE DATE
FLORENCE LI 970 E. MAIN ST, SUITE 200 02/15/2006
IF NE: SANnARTR
Y NO. CONTROL NO,
(800) 835-5946
ARCE1=1ENGINEER: BUILDING MRMR INFO
BLDG ELECT PLUMB MECH
0 0 0 0
.06 ucP19sEDrnNTRACIDR'sDECLnannoN Job Descri tion
r6 C 1 Ivchy.IRrm INt 1 un IircvM wWcr pmvivw aof Chapw 9(mmmucing
TI P
U IhScclionIX )ofDiviuoo3ofda,Buiti.and P CLciouCode.and toy loccoela REPLACE WATER HEATER
' M full fma W e
3 lx.a 3 7 4-5 7 3
y�i Liceoe Ct
nFp Dare AR �omretm A ON (({p..�S�� p
y 77WWu 1 urgvnvd m is a FIN
Ltl.kxvcd Pmfution.
O OWNER-BUIIDL f DECLARATION ED
f 1 hereby affirm Nal 1 am c.cmpl filum the Conoaclm'a Litrn c ty o for Ile
p O follnwlnG moon.(Salion]0]13.Busvras NO Rafutiov Cuda,:Any c11Y m county v]rf fl
i$ which leyuim..permh to umslrlel,.Ile[hnprom oc-d h,m mlmir any nrutture Ltf l��$8 5 0
print mils inuuicc.alw lequina lhrapplkanl for Such permit to filo a v:nad nine—ol
< Imlbci.ulnnacd pursuant mdellm.:flaneofthocontractoriU.Lrtw(Chpmr9 Sq. Ft. Floor AreaValuation
.0 (con.noin:withSction]000)of Diviaioo 3 of the l and Prafcavav Codc)or
than,be 13 eaemPl dsm(mm ud thc Nva for We Mki aempti«i.MY violation of
Sation]031.5 by av alrpti nl Inc.pemdl subjects theap k-ot to a ddl paahYd
ool mare uhao B.e hurMd cid Wer(g5(pl p Ye.yPe�
❑I.uvwanoflM PaPmY.«mY employaa whh w•ga••Iheh ode rompenmtba
willdu the v«k..td lNarrucwre hrot inlerdcd«offered fm,ale(Soc.]OM,Buvneas Re uired Ins ctions
and Pro(adtw coda,TLe Cwtaauors L.iceme Law dors not apply ban pwrer of q pe
pmpc^y who b„iMi or impvlea boom,and who doer swh watt birrac3(ar through his
won emPbyca,provided Wu such ImFrmxmema art not nwdod oroffened frreale U.
hrwav,tic building or bnpmsxmcnl i.add within ore yearof emnpletion.0e owns
Wilda wip ha.x the buNon of prorint that N did not build or Impo,e for purpox d
flak.).
❑1,u when d the(Soc.
7 y,,B Incas tool r cssiorr Cod )l C contnams U.ccruo La NC es not ,pl.]tan vvnor oL and ny w1ulma da or n M,res br'a old
warelowdna WIapprYmusowmroar tortr whoacdrntMgoaa Norton,and
LN contracu f«ancb Pmleera with a cm.anm(s)tinned pmwanl b the ContrattoYa
Le oe Law.
❑1 am evmpl uMa Sec. .B k P C fm bis nems
O«a Dal
WORKERS COMPENSATION DECLARATION
I hereby a0bm tmEer pmlty of perjury.of IK(oibwing dclaradors:
1 haKand MB mvmai..cutlf^,^ac to slf.t.I.Wrote.c«npc
a.don,a prorWcd for by Sctim13-/f10 of Inc Labor Sade.for de'f..of de
Mk for which this permit IS hsoed
1 haw and win mvonin Wortefs Canpenudw Innrucs,u requ'ved by Sredon
]00 of the Latbur Cade.for de pertmmana of the wort for which Nis pemtit lo laved.
My Wor 'a Co IsvWon lar ¢atria Polity numbs ere:
Cama: kulkklNr:14503-oed
CE MCA 'OF EXEMPTION FROM WORKERS'
COMPENSATION NSURANCE
Inds¢cionnerd Iml be completed Ods permit h f«ms huMrtd da0vs(3100)
or W )
I certify hal In the pertwmaax Of th wort for which thot permit h uacd.l still not
employ ally peraon in any mmituso u to bcmtx abject to do Wortcn'Campenvdon
Ion d Cali(orrtia.Dalt
Applicanu
NOTICE TO APPLICANT:IL afu matin:Ihh Catifc.e d Eaempdon,you should
become abj n b the Worta's C.N.H.ancom..d rite IAlmn Code,yoo must
.J O foMwith comply wiuh loch pmvisiov or Nis permit shall be dccmed nested.
z N CONMUCDON LENDNG AGENCY
[r r. I llcmby.M.that den it.mrwucti.lending a:ecy for the performame d
G'4> de wort f«which Nis permit h iulsd(Sec.309'1.Civ.C.)
W� Q Lord 'Name
z Leucin',A,c,
U O 1 cc t ry Nu 1 haK road this.pplkuim and sum don tN.bose infeam.don is
U. N codon l spa to comply wish all city and county ordimrces and alns hors relating b
0 U Wildingconawtiom.nd hacb,inn orirt rcp owi.raof duh city to court upon tic
.hove mcmi«vd propertY for V.
PML
PML
F0. (Wc).gra masa,hdrmnify and bap hanokss the City of C.Ilanirm againu
rn Iitat idu,judgmcnmcaw and capcvca which may in my way accrue al waaid Cly
U z Incovcgoctmcofthc gra Gdth1Spc�IL
�-^ APPLICANT UND C NDS N-P01Nr Issued by: Date �SOURCEREGS oL Re-roofs
Sign ronco(ApplicanoCm=lco Due
HAZARDOUS MATERIALS DISL0!iUU Type of Roof
Will Ito al or fuuuc Wilding occupant mace or handk ha.udous m.whl
ad dcftned by the Cupenita Mwicilul Codc,Clupm,9.13,and the Hcalth and Safra
odc.Srction 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yu
Will too.,11.1 or too.building ncmlpanl ere equi,.or dcviaa which If a roof is installed without first obtaining an inspection,I agree to remove
II h.cl air wntamirwtu as dcfucd by tic Bay Arta Air Quality Mavgunat all new materials for inspection.
D '
w nOYm
I hate eW Ne hvandcr..maaiiahncquitvraas wdcz CNprr 6.95 of de Califon
ria rlalth k NSafmyCodc,Smims 25505.25533 W 25531.1 o dumvd ihmifdc building
doca.m.m«Iy or Wm,dodhi, pm it.). :mnotifybe reldJr
rcgaimtery which be met an(.c fi.olocmr Signature of Applicant Date
5/a6 All roof coverings to be Class "B"or better
owner or aur rind a6xnl Dam
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
II 4PPEkTINO
Building De artment
JOB ADDRESS: 1
0
/810
PERMIT #06o ZOC3 q S
OWNER'S NAME: PHONE # - 2-Lo
GENERAL CONTRACTOR Q FAX#�
I am not using any subcontractors: J.rJa4 Y- Yu - &A;-,�
Signature Date
Please check applicable subcontractors and complete the followinginformation
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
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile-/
/.0 M arc,.
Owner/Contra tc or Signature Date
CITY OF CUPERTINO 9
WATER HEATER
�UPEkTINO PERMIT APPLICATION FORM
APN# 3� Z / Z Date: Z ,5/0 1
Building Address: /O/eO Com`
Owner's Name: / I Phone#:
1-l4 G - 2-6 o s
Contractor. Ph ne: License #:
a �W S--SW4 3 -7 (4s -73
Contact: Q Phone:_ Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech '❑
Job Description: /e-,- A a
_ q ,
Residential �t/CooammCercial r-1 t
Cost of Project: S O w
Strapped LJ On Platform LJ Bonded
New Location ❑ Re lacement x
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/ Vent BUILDING
I PPERMTTFEE Plumbing Permit Issuance PLUMBING
1 BENERGY Energy BUILDING
BUSLIC Business License BUILDING
3 3 -2 �