05100216CITY OF CUPERTINO
"�
BUILDING DIVISION PERMIT
UNTRAGT'OR,N;R1'�'�TAN',
BUILDING ADDRESS:
ALL VALLEY PLUMBING
FERMrr No. 05100216
22625 SALEM
ER'S NAME:
PERMrr ISSUE DATE
ROBERT CHAO
170 BEAMON DR
HONE:
SANRARY NO. CONTROL NO.
(510)376-4816
ARCHnEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby am. Nn I me licensed under provisions of Chapter 9 (commencing
Job Descri ti
p
withrwn7Q70) of Divi n7 afNs Buvnexa pro(esfivrss Code, and my lkums k
m sen farce and
0 to f m
REPLACE WATER HEATER �'�
ALE®
Lie. P
Dam
CHRECI-S DECLARA ON
1 u.dewnd tatta awl ad used u rtemN
1'
NO
F1'Licensed
y Ppublic
I
1005
Professional
OWNEOER DECLARATION
I thereby M. Nm I sean exempt from NeContera License Toon for tits
fallowing recon.(Section 7ID 1.S. Busiaw and Pmfesaiou Cods: My city or=.my
y'P. rfr
which mqulas a permit on convect, cher, harrow. do ralim. or mrsto my structure
s fff777 ��`11171
prior to its imwnce, also requires the applkmt for such permi, he file a signed matemem
Conhxmra IJc"vc law 9
Sq. Ft. Floor Area
V alua dA
Nad he is licensed parvus he Ne pmvisiam of Ne (Chapter
(commencing with Section 7000) of Division 3.f the Burins mud Profession. Code) or
that he is attempt ticnefrmn send Ne buts for the alleged emmpilon My violation of
P U U
Occupancy Type
Section 703" by any applicant far a permit subjects the Applicant 10 1 civil penalty Of
not mart than Rw hundred dollars (5500).
.0 I. as owner Can, properly, Or my wplaym with aagn as nab cele careprasstion,
Required Inspections
q p
will do du work and rte structure is set intended or o@red for Mit (Sec. 7044, Buurcaa
Md Pm("daos Code: The Camreetoes License Law does set apply to an aur" rof
pmpeny who builds m Improves thereon, and who does such nark hhMdf os through his
ownemployen, provided that each impmvemuua me not Intended orofroad forsale. if.
'
however. the building of Improvement is mid within one Yew afmmPletion, Nc earn"-
bullder will have Ne burden of proNng Nat he did nm build "improve far purpose of
sale.).
❑ I. u owner of the property am exclusively contracting with licensed e0atra'1an m
-
construct Ne project (See. 7044. Busmen and professions Cade) The Contractors LI-
"um law chase not apply an an own of propeny'who builds or improves thereon, and.
who NntflCm fm such projects war a conummas) licensed pmmanl an Can Contractors
LlceNe L...
O l am uempt Caner See ,B h P C fm this seam
Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ane of Ne following de<tumims:
❑Iham end te
of Consentmtede.far
eCsrti 37W Cutperformanceof
smion, provided (ec by Section 7700 a( the labor Code. far Ne pedormuev of the
for
t
ooh for which Nis prnnit is laud
❑ 1 haw and will maintain Workers Compensation Immmm, u acquired by Section
1700 of Ne labor Code. far the peRormance of the work (arwhich this permit is Isov,d
My Workee CompensWa /u1rlpn�ce/�art1or and Policy nufm�bAerr sm.
-
FlG -OF EXEMPP0N FROM WORKERS
COMPENSATION INSURANCE
Clhuvtetion need ant bccmnpleted Uthe permit Is raw humbeddonna (5100)
or lest)
I certify Not in the performance of the work for which this permit is Issued. I awl Our
employ any person in my manners u to become subject in tie Wart"l Compensation
Laws of California. Data
.
Applicant
NOTICE TO APPLICANT. IL alter malting NB Cesneau or Recreation. you should
became subject in Ne Workers Competition provisions of Ne Labor Cade you mute
.
foMwith comply with each provisioru or Ni. perch shall be decreed ranked
UCfION LENDING AGENCY
1hreaffirm " dem sennsuuedm leading agency for tie perfauee of
them te
which
tits woe fur which ntis permit is "sued (S". 3177, Civ. C.)
pe
Lendn. Nemo
.,.n.e. Addrea
1 cesti(y that I in" rad dar application read state Nm Ne above Information Is
4 coram I agree an comply with all city and county ordinances and sum taws relating to
building con.mction. Md hereby mNartre reprema . ives or Nu city Center upon tie
aeove-mennuned sspc mon purposes.
(We to sew. h' msfy and keep lumn ca Ne City of C.Pertim again
I Ilabiliti udW�Qmenucom which may In my way acemc aPiat Mid City
In cAPDWI COMPLY WrrH ALL Nr-POINT
Issued by: Date
S
Re-roofs
Type Roof
_
Signmurc a(AppB HAZARDOUS
MATERIALS DISCLOSURE
of
Will the applicants or forum building eccuPantad"e orhandle hazardous material
u defined by Ne Cupertino Municipal Cade. chapter 9.13, and the Hath and Safely
Section25532(.)?
All roofs shall be inspected prior to any roofing material being installed.
Oyu ❑Na
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant ti equipment Cr devices which
.11 huasnos air canuminanu u deRned by the Bay Area All Quality Mmugemenl
all new materials for inspection.
District?
❑Yes 0N
I ham mad site huuthos mmomisrequlmmem, undarLTm ant 6.95 ornn Callon.
nia HcalN85afe1y Code. .25373 ad 25534.1umkrswu deadline Wilding
do"set tkmyr"ponhit ily m and l'y Me =am, am, INe
L
ms ohm x et rmw .Cenincmeer
ignature of Applicant Date
All roof coverings to be Class "B" or better
owner ad e D
rl, r
CI OF
UPEI�TINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Buildin gcr Department
JOB ADDRESS: fk�,
I am not using any
Please check applicable
/ Signature
and complete the following information:
l<,;ZvD
ate
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
I am not using any
Please check applicable
/ Signature
and complete the following information:
l<,;ZvD
ate
Owner/ Contractor Signature Date
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
U
t• I 1 of 1
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 34212064.00
DATE ISSUED.......: 10/27/2005
RECEIPT #.........: 31760
REFERENCE ID # ...: 05100216
SITE ADDRESS .....: 22625 SALEM AV
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: ellen
COPY # : 1
OWNER ............: ROBERT CHAO
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-5648
METHOD OF PAYMENT ' AMOUNT
----------------- ------------
CHECK 186.02
TOTAL RECEIPT 186.02
VOICE ID DESCRIPTION
502 FINAL PLUMBING ENERGY
507 FINAL PLUMBING
0
NUMBER
------------------
6734
VOICE ID DESCRIPTION
____________________________________
506 GAS TEST
RECEIVED FROM ....:
ALL VALLEY
PLUMBING
CONTRACTOR .......:
ALL VALLEY
PLUMBING
LIC # 23015
COMPANY ..........:
ALL VALLEY
PLUMBING
ADDRESS ..........:
170 BRANNON
DR
CITY/STATE/ZIP
...: TRACY, CA
95376
•
TELEPHONE ........:
(510)376-4816
FEE ID
UNIT QUANTITY
AMOUNT
PD -TO -DT
THIS REC
NEW HAL
----------
BENERGY
------------- ----------
PERMIT FEE
----------
1.00 134.86
----------
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
BUSLIC
FLAT RATE
1.00 102.00
0.00
102.00
0.00
TOTAL PERMIT
----------
186.02
----------
0.00
----------
186.02
----------
0.00
METHOD OF PAYMENT ' AMOUNT
----------------- ------------
CHECK 186.02
TOTAL RECEIPT 186.02
VOICE ID DESCRIPTION
502 FINAL PLUMBING ENERGY
507 FINAL PLUMBING
0
NUMBER
------------------
6734
VOICE ID DESCRIPTION
____________________________________
506 GAS TEST
0
•
CITY OF CUPERTINO
WATER HEATERri
lPt=QTINn PERMIT APPLICATION FORM
Qty.
1. ,i In P.. m Fee Descriotion Fee Group
!l II.0.UIl. � vv
BPWHEATER
Water Heater / Vent
BUILDING
PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BPERMFEE
Bldg Permit Fees
BUILIDNG
BMITIGAT
Housing Mitigation Fee
BUILIDNG
BPLANCHK
Plan Check Fee
BUILIDNG
BUSLIC
Business License
BUILIDNG