06020055 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTORINFORMATI0 ,
BUILDING ADDRESS: AFFORDABLE WATER HEATERS PERMRNO.06020055
22430 PALM AVE
NER'S NAME: PERMIT ISSUE DATE
JASON HENDERSON 24707 SAN FERNANDO RD 02/09/2006
PHONE: SANITARY NO. CONTROL NO.
(661) 259-7131
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
000 LICENSED CONTRACT'OR'S DECLARATION- Job Description
mF 1 Mmby affirm That 1 am limned under pmvWs of Chapter 9(eommencin{ P
4Zwith Section tIXlU)of DivisionJof she Businecxand Professions CoM.aM mylicenscis
E
in full anaen 6 Last �2736� REPLACE 75 GALLON WATER HEATER (SAME LOCATION)
j�? Lfullt =a
ny p Dao; Conuarlor
ARCHITECTS DECLARATION FINALE®
a
U I unacrmad my plans shall he.. u public records
;off Licensed Pmrcssinnel
3 OWNER-BUILDER DECLARATION
ny I hcmhy affirm Nal 1 am exempt from the Contractors License law far the
no rollowing reason.(section AD I.S.Busincer and Profusions Cade:Any city or county MAY rue
m F which mquires a permit to enrmsact alter.Improve,demolish.or repair any mrumam — S si5oo
prior In its issuance.also require the applicant for such Permit to file a signed summ[m
?< that kislicensed punuemtothe provisions Ofthe Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
zFC (commencing wish Section 7MO)of Division of the Business and Professions Code)or
y
that he is attempt therefrom and she buts for the alleged exemption.Any violation of Al
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom rev,five hundred dollars ISM g Pe
❑1,u owner o(the property,ar mY moployce with wegu u mess ulc compensstion,
will doshework ands: he Comtunotinse. Law
(Sec.to ad,Business
and property
W Cane:The canuxmra exam[Taw sae act apply m,n awmr is Required Inspections
Own crtywho Handsmburrows hmpn.eauveno daosantwork Mmu1redmrou{h his
ownemploycuiping or i provemimprowmenuart not ear ocdmoB[md fm We.Ir. -
howewA the building or improvement of P. .is sold within one Weld or completion,the owncn
builder will have the burden of proving than he did ret Wild or improve for purposes of
sale)
C]1,u owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Conn tess Li.
came law dors not apply m an owner of pmpeny,who Wilds or improv themon,and
who contracts fm such projects with a contracmr(s)liwesed pursuant to the Convectors
License Law.
❑I am exempt under Sec .B B P C for this mason
Wer Dna
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penahy of perjury ane of the following declarations:
1 haw and will mainuin a Cerofiem of Canunt mself-insure fo WorketsCompen-
sation,as provided for by Section 37M or the Isbor Code,for Bre performance of the
work for which this permit is issued.
O 1 have and will maintain Workers Compensation Imurana,as required by Section
3700 of the labor Code,for the performance of the work for which this permit is issued.
My Wark4rs Compensatio9 nsunntt carrier and Policy number art:
Carrier. Ze.N 1 Policy No; `--C/o7b%O 70
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Tuissection sed not voomplemd if the permit Is forma hundred dollars(SIM)
or less.)
1 cxofv that in she perfurart.of tic work far which this Permit is issued,I snail not
employ any pereen in any manner an a to become subject a the WorkersCompensation
Laws of California.Dam
Applicant .
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject m the Worker's Compensation provisions of the tabor Code,you mum
.,Q roMwitn comply with such provisions m this permit shall W deemed revoked.
Z ` CONSTRUCTION LENDING AGENCY
(--�� IWreby.M.Nat them iso construction kndingagency,for she performanaof
6ai the work for which this permit u issued(Sec.3W7.Civ.C.)
14 A Lenders Name
m z Lender's Adtlmss
U 0 1 certify that I have mad this application and sum that she show information is
Fcorrect.I agree to comply with all city and county ordinances and sum laws relating to
DU Wilding construction.and hereby amboim repreunutiv or this city to enter upon she
r N.1 alwveties.,ohm Property for inspection purposes
Ewa Iiabiliti(We)amc osaw,inaCmnif�d keeeAyywalacetwellamstmodc.11
hh'rmless the City of Cype!tum!pimt
N pc
z Aco nee E in{or Nis permsAP NT NOE ANDS AND WIWITH AL�OtJaAO� Issued by: Date
U E R ULA NSv 1
Re-roofs
Simetre of Appiica ox ontracmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Out,applicant w future Wilding occupant store or handle havamous material
as defined by the Cupertino Municipal Code.LTapmr 9.12.and sh[Health and Safety
. 255320)1Dy. All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtainingan inspection,I agree to remove
Will theapplicant
e.am or ons a building by the Bt use equipment or device which P g
emit krardnus air canuminants ns dconcd by she Bay Ama Air Quality Manegemcnt
District' all new materials for inspection.
❑Yes &K.—
the
e,a'theh us ma a mqui.7 sonderCkpter .Q95arthe Califor.
nice"cam SarayC do 50�255JJ and 2553x. tdcrsuM thazif the Wilthng
dos no,[ s n l ren/'tss my raponsibil' m notify the aceupant Ory.
re entswhic to et eifnmica a B ora up�ey G Signature of Applicant Date
Owncroraumorized agcm �/ ate t All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
PEkTINO Fax(408)777-3333
qu
Building Department
JOB ADDRESS: Z Z430 PAlw^ A v< PERMIT #
a &a �-86 s-s
OWNER'S NAME:SA Sot,J e,jparsa ml PHONE # YO -54 C - 71(r
GENERAL CONTRACTOR:if ffo✓Aafi L� , /FFA`jX/#
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
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
I• 5 of 5 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 35704016.00
DATE ISSUED. . . . . . . : 02/09/2006
RECEIPT #. . . . . . . . . : 33152
REFERENCE ID # . . . : 06020055
SITE ADDRESS . . . . . : 22430 PALM AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : JASON HENDERSON -
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . : CUPERTINO CA, CA 95014-2710
RECEIVED FROM . . . . : EDDIE NALLEY
CONTRACTOR . . . . . . . : LEONCE ROUX LIC # 26850
COMPANY . . . . . . . . . . : AFFORDABLE WATER HEATERS &
ADDRESS . . . . . . . . . . : 24707 SAN FERNANDO RD
CITY/STATE/ZIP . . . : NEWHALL, CA 91321
• TELEPHONE . . . . . . . . : (661)259-7131
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
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ----______-__---_-
OTHER 420.10 M/C
TOTAL RECEIPT 420.10
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
CITY OF CUPERTINO OCaMDD55
WATER HEATER
an of
CUPERTINO PERMIT APPLICATION FORM
APN# / Date:
J
Building Address:
r1,�430 �glrn A�2.
Owner's Name: Phone#:
)o.SDr\ 1 C0trsoti
Contractor: Phone: (r(a c License#:
jerfo( ab e N-re QAT2.fS LN -313 ) te�7 �b8
Contact: Phone: (Pbl Cupertino Business License#:
Co"lT L1iT11�50
Building Permit Info: J
Bldg ❑ Elect Plumb Mech ❑
Job Description:
RePIGC2 1S WgTef 1�2ciTQr (�Qme I000.r�On
Residential Commercial ❑
Cost of Project: ( SO D
• Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replacement IT
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERM=E Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
•