11120015 ' CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21104 WHITE FIR CT CONTRACTOR:WOLFGRAM CHRISTIAN K PERMIT NO: 11120015
AND SHERYL L T
OWNER'S NAME: WOLFGRAM CHRISTIAN K AND SHERYL L T 2362 GARNET STAR ST DATE ISSUED: 12/01/2011
R'S PHONE: 4083169919 HENDERSON,NV 89044 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION C r_1r
BUILDING PERMIT INFO: BLDG ELECT PLUMB "'
License Class Lic.k
MECH r RESIDENTIAL r COMMERCIAL
Contractor Date
I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:WATER HEATER REPLACEMENT IN CLOSET IN HOUSE
(commencing with Section 7000)of Division 3 of the Business&Professions -RETROACTIVE PERMIT-
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one orthe following two declarations:
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
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$200
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:35905086.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued by: Date:
Signature Date
OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall he inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Low for one of installed without first obtaining an inspection,1 agree to remove all new materials for
the following two reasons: inspection.
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE.
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(x)should 1 store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should 1 use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work forwhich this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I Owner or authorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
iftnify and keep harmless the City of Cupertino against liabilities,judgments,
JWand expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section 1 understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Dele
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: bethe
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35905086 . 00
DATE ISSUED. . . . . . . : 12/01/2011
RECEIPT #. . . . . . . . . : 99000000698
REFERENCE ID # . . . : 11120015
SITE ADDRESS . . . . . : 21104 WHITE FIR CT
SUBDIVISION . . . . . . :
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : WOLFGRAM CHRISTIAN K AND SHERY
ADDRESS . . . . . . . . . . : 2362 GARNET STAR ST
CITY/STATE/ZIP . . . : HENDERSON, NV 89044
RECEIVED FROM . . . . : CHRIS WOLFGRAM
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : WOLFGRAM CHRISTIAN K AND SHERY
ADDRESS . . . . . . . . . . : 2362 GARNET STAR ST
CITY/STATE/ZIP . . . : HENDERSON, NV 89044
TELEPHONE . . . . . . . . :
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW SAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
OLBCBSC VALUATION 200 .00 1 . 00 0 .00 1 . 00 0 . 00
OLPLMPE FLAT RATE 1 .00 44 . 00 0 . 00 44 . 00 0 . 00
OLSEISM VALUATION 200 .00 0.50 0 . 00 0 .50 0 . 00
OLTRVDOC FLAT RATE 1. 00 44 . 00 0 . 00 44 . 00 0 . 00
OLWTHTR EACH 1 . 00 26 . 00 0 .00 26 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 115 .50 0 .00 115 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 115 .50 visa
---------------
TOTAL RECEIPT 115 . 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
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518 WATER HEATER
•