06070137 (2) CITY OF CUPERTINO 71ONX
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aUILDINGafVISION PERMIT 1xCO�£TR .CTaQR T"^�fi'"m SAT
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BUILDING ADDRESS: WATER HEATERS ONLY PERMIT NO.06070137
7565 DE FOE DR
OWNER'S NAME: PERMITLSUBDATE
DR. TOM HSU 970 E. MAIN ST, SUITE 200 , 07/20/2006
NE: SANITARY NO. CONTROL NO.
(800) 835-5946
ARCHITEC UENGINEER: BUILDING PERMR INFO
OBO PLUMB NMECH
LICENSED CONTRACTOR'S DECLARATION 70b Description
I hereby of ms that 1 am licensed under provision of Chapter 9(Coae
mmlnj
with Section 7000)ofDivimm Sof the Businevand Professlom Code.and my Ikenm is
�h inrullforceand REMOVE AND REPLACE WATER HEATER
,qz Licene Clus 3L' IJc.I
'F Dats Comrac
gg
ARCHITECTS DECLARATION/A TION
i d 1 understand my plane Mall he used An public records
144 U
'off Licensed Professional
OWNER-BUILDER DECLARATION
Z I hereby
aRrm that I am exempt from the Contractors License Law for the .
:no following mason.(Scedon 7031.5.Business and Pmsiou
fesCade:My city or County
f C$Y, which myuhes a permit n cormumcL ahm.imp..demolish,ar¢pair my suucfum n O(]
I.Z�, priormiuissumce..Orquirosdeapplium(Orsuch pennilm0leadgW atsmmt
: � that he is licensed pumssnt m the provisions of the Contractors Litm=Law(Chapter 9 Sq.Ft. Floor Area Valuation
j (commencing with Section 70DO)of Division 3 of the Business and Profession.Code)or
$ dos he is cOmp themftom and the basis for the Alleged uempdon.Any violation of
Section 701.5 by arty applicant for a permit Objects the applicant An a civil PMIIY of MrhYer u u Occupancy Type
Ion mom Nm five hundred dollars($500).
❑1,As owner of Oro property,or my employees with wages As their sok camp tmemb",
will do the wort•and the suuaum is not founded or offered for sak(Sm.7044,Business Required Inspections
and Professions Cade:The Commem's Licemu t Law es domf apply e e an owner of q P
prapeny who builds or improv thereon,and who dons ouch work himsef f or through his
own employrra,proNded that such Improvements son not Watednd oronewd for ask,if,
however,the buildingor Improvement is old within on year of completion,the owner-
builder will have the burden of proving that be did not build or Improve for purpose of
ssle.l.
❑1,a owner of site property,am exclusively contracting with licensed Contractors in
construct thed es moa(Sec.An an
wner of she Profossioos Code:) pe Cantr reen, d
Crude who claw does not apply m an owner of proinutyem(s who builsed p or improve.theran,and J
who contracts for such pmjeas with a eonuactor(s)licensed pursuant As the Cantracmra
Law.
0 14.Tom esempt undo See ,BtPCfor thh on O
Owner Dan /b
WORKER'S COMPENSATION DECLARATION
1 hemby of op under peruity of pedury one or the following declaratiou:
I have and will mdnuin•Cenincam of 0A Ont to self-Wum for Workers Campen-
andan,As provided for by Section 3700 of the Labor Code.for the performance of the
work for which this permit is issued.
1 have and will msinuk Workers Compensation Insurance,An required by Section
700 of the labor Code,for the performance of the work for which this permit is issued.
My Workc aCampeuado Inmran am'u and Policy number are:
Camier.��PoJN No4�s RS' S
ERi COMPENF SATION
ATION ONFRAN WORKERS'
COMPENSATION INSURANCE
rnmissenden need not becampkeJ if Ne permit is I.C.hundnddo0are(5100)
Or less.)
1 Unify drat In the performance of the work for which this rennh is blued,I Mall not
emPloyany person in my mumrm As At become Object to the Workme Compensation
Laws of Califomia.Dae
Applicant
NOTICE TO APPISCANr.IL after matin{this Gourmets of Exemption.you Mould
bccane subject An the workers Compcmdm provisiwu of also labor Cade,you most
.,O forthwith comply with such provisions po
ons or thermit Mali be dmed reveled.
Z` CONSTRUCTION LENDING AGENCY
(+ 1 hereby afMn that Nem is a conewction Imdin{agency rot the PerformanCo of
rL the wort for which this permit Is IoW(Scc.7097.Civ.C.)
a0 Lenders Name
= z Lenders Address
U Q i certify dot I haw rad this Application and sue dm the above information is
Ly t" comtt 1 agres to comply with all city And county ordinanm and state laws relating to
O U building Construction,and herby authorise representatives of this city to enter upon the
�Ctl move.menutmed property for iospeeuon purposes.
F^6. (We)ogre to save,indemnify and keep harmless the City or Cupertino against
to Iiabilitie,judgments,cosu and Cap.which may In my way.cave aiaiut said City
U in conmgvene,of the{mating of this forth.
.. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGTI_ ON ?11"
Re-roofs
Signatun ol'ApplicatruConLillmor Date
HAZARDOUS
MATERIALS DISCLOSURE Type of Roof
WIII the applicantor(Mun Wadinge.Chaptnormandte hulthand attlous Ssodsi
As deRned by ale Cupertino Municipal Code.Chapter 9.12,Cosi dace HGIth mJ Safety
Cod.,SeNon 255324)? All roofs shall be inspected prior to any roofing material being installed.
41 ❑Yes Q Nu
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit havudous air conumlmnts As defined by the Bay Arca Air Qualify Management all new materials for inspection.
District?
❑Yes 011bi—I
1 have mad the hmNnosmatsdalemyuirmcnu under Chaptsr6.95 of the Califon
ria Health k Safety Code.Saetlens 25505,25533 and 25534.1 understood that if the building
does net cunenlly ham a tenant,that it is my rspmulMlily As notify dso Occupant of the
mq.ir ich most xmy(priorm amaowofa Ccrdfloanofoce pmcy. Signature of Applicant Date
'—�" �•t` 1 All roof coverings to be Class"B"or better
Owneroraulho ed agent Dau'
CITY OF CUPERTINO
Sm 2 of 3 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35925017 . 00
DATE ISSUED. . . . . . . : 07/20/2006
RECEIPT # . . . . . . . . . : 35328
REFERENCE ID # . . . : 06070137
SITE ADDRESS . . . . . : 7565 DE FOE DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : DR. TOM HSU
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : BONITA JENKINS
CONTRACTOR . . . . . . . : MCGEE, PAT LIC # 18986
COMPANY . . . . . . . . . . : WATER HEATERS ONLY
ADDRESS . . . . . . . . . . : 970 E. MAIN ST, SUITE 200
CITY/STATE/ZIP . . . : GRASS VALLEY, CA 95945
TELEPHONE . . . . . . . . : (800) 835-5946
EE 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
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Community Development
10300 Torre Avenue
r Cupertino CA 95014
Telephone(408)777-3228
C Fax(408)777-3333
WPEI�TINO
Building Department
JOB ADDRESS: 7565 PERMIT # 7 a / 7 �2
OWNER'S NAME: n Dm PHONE # 6, 6 6 - 0 6 /
GENERAL CONTRACTOR ,Q FAX#�
I am not using any subcontractors: Ur 4 1,4eAbs, i2)iA
Signature bate
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 ate
CITY OF CUPERTINO b lQ l o 131
WATER HEATER
*UTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
Owner's Name: (1 I,f Phone
Contractor:/, ' `F4•Phwne: License#:
Gf/ $'c)c) S-SW6 3 -7(4s -7 3
Contact: Q Phone: 9Cupertino Business License#:
D7-waw /00, 9 8'6
Building Permit Info:
Bldg ❑ Elect Plumb Mech
Job Description: te*- R
Residential 0Commercial ❑
Cost of Project: ,7 0
pped On Platform Bonded
New Location ❑ Re lacement x
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
I PPERMITFEE Plumbing Permit Issuance PLUMBING
I BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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