08100104 CITY OF CUPERTINO pa=, +�.etvs<v s'•.:'r3 •'•P»ro' 2t` fig:;,
BUILIjING DIVISION PERMIT CQN1JU1 —9-- t1 QRMA.TION' I
BUILDIyy,G, O FSS: PERMITNO.
1Ut� SENATE WAY AFFORDABLE WATER HEATERS & 08100104
'NER'S NAME: PERMIT ISSUE DATE
ART BALAGULA 24707 RAILROAD AVE 10/17/2008
PHONE: SANITARY NO. CONTROL NO.
(661) 259-7131
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
r I 0 0 (�
u0p LICENSED CONfRAC1OR'S DECLARATION lob D05CflpnOn
I hwby vinw Wt I am liwnsnd under provisions oI CWptmeYnd(commencing
with Swtion]0(IU)afDivision 3afthe Busineea sad Zf/ 3Ynd! myliecnseis REPLACE 40 GALLON WATER HEATER
^ % in full forte and L Y
j�z Wcense Lasa -LN.•
F p Da¢ Contractor
e 7th ARCHITECTS OECLARA ION
e w< I understand my plea shall W need as public records
�C t Licensed Pnefessiennl
OWNER-BUILDER DECLARATION
f 1 Withy o?rm Nat I am cumpl from the Camnnaes Leon.Law far the
a0 following mason.(Section 7031.5.Business and Professions Code:Any city or worry
E
m�+ which m,rou,,permit to construct.ailcr,improve,dcmolisR or repair any swctum
°iy priorb its ns th
issuance.,lan nequire applicant for such pewa file le a signed summer
i< Met heis licensed pw
oant to the novisious of dee Comncwr's Licemc Law(Chapmr 9 Sq.Ft. Floor Area $1600 Valuation
yha (commencing with Section 70)(1)of Division 3 of dm orb Business Profen ions Code)or
i 3 that he is esempt th=re(wn and the basis fm the alleged eawptim.My violation of
Section 7031.5 by My ppimsnt far a permh lubjece the applicant in•civil penalty OfNumber Occu Type
nor mom War finberdm ).ddollarsIS 32653012 �� parc y yp
❑1.ssowrm of the poperry,armY wplayeea with wgawa thc'v sole compewtim,
will do the wort and Ne strumae is ret intended M afferent per rale(Sen.TOM,Buvowea
and Professions Codu:The Cormawfs Lion¢Law does Out apply In an awns Of Required Inspections
propeny who WildiarimproveslherennaM whodousucle work himself.through his
own wplonins,provided dot such improvemerU,re not intended oroffoot!fm sale 11
herwmrv,Ne Wilding or bnprovemast is said within orc year orcwpletion.We owner-
Wilder WH ban the WNen of pmHng that h=did an,Wild or improve for purpose of
tele.).
❑1.as owner of doe property,am melusively committing with licensed consolidate in
construct We Lomita(Sec.7014.Businm,nd Professions Cade:)The Comncber's U-
ccoue law dons not apply so an owner of property who Wilds or impmses thereon,and,
who comment for such projects with a eontraear(s)licensed pursuant in Wo ContraclaYs
License law.
❑l cam exempt under See .B&P C for this mason
Omer Dam
WORKER'S COMPENSATION DECLARATION
1 thereby affirm under pensity of perjury ace of We following declarations:
❑ibe.and will m,inminaCremliateof Consent a self-inawfmwmteYsComp=n-
wtion,
woh for which this
by Sensors 3]00 of the�r Code.(m the per(ormaoow of doe
pewit is issued. '
❑1 have and will maintain WOWSYs Compwadan lasiu me,as required by Schon
37M of We Labor Code.far We perfars.of the wart far which Joie Pewit is issued. '
My Wimk '`Co^m^psI¢'s�auon hours.concrete!Polity nuinteMPr, yam•
Camen2�+v•T ` Policy NoQ sem' 1
CERTIFICATE OF EXEMMON FROM WORKERS
COMPENSATION INSURANCE
rllussemton acted an,W complet:dJWe pewit Is fwonchundN dollars(5100)
sir leu)
1 cmtiry that in the pmformarzO of than week far which this pcmit is leaned.l Shall not
employ any pe.a in any mmrtec as as in become subject in We Weaken'CompwaBan
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Eswption.you Would
become wbjw a the WorkcYs Compensation provisions of the laner Cade,you muse
.JO fOMWIW ns or with each provisiothis Pewit Shill W demrevoked.
oked.
„zoo CONSTRUCTION LENDING AGENCY
[-a Ihemhy.M.that there O a construction lendingagmory far We perfurmoncc of
sol 7 We.,it fur which this pewit in issued(Sec.309T,Civ.C.)
!L7 0 Undo's Name
,a z Isndces Address
U Q 1 certify that I here mad this application and sate thin We aWve information is
D. f coma 1 agree to comply with all city and county oNinarxee W sake laws mining a
.0U Wilding construction, M on,, hereby authalme representatives of this city a cater upon the
r W alive-mentioned proa ny for imp=Won purposes
(We)agroe to wave,indemnify and trip harmless the City of Cupertino against
F y liabilities,jWgmenu.costa and.aper...which may in my way aware aguoul said City
V Z in co uce,mance of the granting of Nu pumil
'-' APPLICA gDERSTANDS AND WI MPLY WITH A11��NON-POINT Issued by: Date
SOUR EGU TI ( /-7/G
/r Re-roofs
Silimmuffaf AppliaAROr Dia
HAZARDOUS MATERIALS DISCLOSURE Type of Roof '
Will NeApplicant sir forum
ss . Wildingtswor wnemaariai
de the Ma Mustin Code.Ompter 9.12.andl thHeaith and Safetysectiionu532(,)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yne No
Will the applicmt or
fuhim build'r pint use equipment or devises which If a roof is installed without first obtaining an inspection,I agree to remove
=mit havardane air contaminants ss J by We Bay Arra Air Quality Msnag:mcm all new materials for inspection.
Dimict]
❑Yes Nu
1 have mail the iteration materials requirements under Chapter 6.95 ofthe Califor-
nia Health&Safety Cade,Seen.25505,25533 and 25534.1 understand Won ifthe Wilding
doe Out cuwnthy have a Wens Wu IL is my iuibiltry a Madly do�ep as�3p'�a�ns of We
requirements whi IW met priorsaraJ, �7/G7- Signature of Applicant Date
( y
owner Or authmcd s=sitAll roof coverings to be Class'%W'or better
o ' Daa
• CITY OF CUPERTINO
4 ITEMS OF 12 PERMIT RECEIPT OPERATOR: suew
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . .. 32653012 . 00
DATE ISSUED. . . . . . . : 10/17/2008
RECEIPT #. . . . . . . . . : BS000006379
REFERENCE ID # . . . : 08100104
SITE ADDRESS . . . . . : 10112 SENATE WAY
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : ART BALAGULA
ADDRESS 10112 SENATE WAY
CITY/STATE/ZIP CUPERTINO, CA 95014
RECEIVED FROM . . . . : EDDIE NALLEY
CONTRACTOR . . . . . . . : LEONCE ROUX LIC # 26850
COMPANY . . . . . . . . . . : AFFORDABLE WATER HEATERS &
ADDRESS . . . . . . . . . . : 24707 RAILROAD AVE
CITY/STATE/ZIP . . . : SANTA CLARITA, CA 91321
• TELEPHONE . . . . . . . . : (661) 259-7131
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---- ----------- ---------- ------- ------ ---------- ----------
1BSEISMICR VALUATION 1, 600 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1PRWHEATR UNITS 1 . 00 24 .48 0 . 00 24 . 48 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 .79 0 . 00 40 . 79 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 106 . 56 0 . 00 106 . 56 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-- ---------------------------- -------- -----
---------------
518 WATER HEATER
Community Development
i 10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
�UPEI�TINO Fax(408)777-3333
Building De artment
JOB ADDRESS: PERMIT #
10 1 D `
�'"z- S e�.N e- w / 7
OWNER'S NAME: Rrk PHONE # ya62 (�-7
GENERAL CONTRACTOR:fa1 (6,oe„� ✓( J✓ F -#
I am not using any subcontractors: lO /1-7/0'�
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
Dgm,
CITY OF CUPERTINO
WATER HEATER
•CUPEROTIN0 PERMIT APPLICATION FORM
APN # s'3 �.�1 Date-
lu/l7/oY
Building Address:
Owner's Name: Phone #: y
`
°
Pfrk
Contractor: Phone #:6G) —ZS S _ 71 3
�}�o✓U A(31� c,-7�,.a-�- �tom.
Fax #: (o6/ vsciSs Sb
Cupertino Business License #: Contractor State License #:
o2\& 0!U73 (- b'
Contact: Phone #:L�_ 7_,�r,7, /3 f
�Co44- L(� 4,- rt - Io Fax #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb 0 ' Mech'[:]--
Residential Commercial ❑
Job Description:
(40
Strapped On Platform r Bonded LJ-- New Location ❑ Replacement ❑
Valuation (cost of project):
DU
Project Size: Express Er Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to
the application or if applicable, include in plan set & the sheet index.
Green Building Points achieved:
Revised 6/16/08
-a CITY OF CUPERTINO
WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCWHEATR Commercial Water B PCWHEATR
HeaterNent
1BSEISMICOM Seismic Commercial B
1PRWHEATR Residential Water B PRWHEATR
1 HeaterNent
1BSEISMICRE Seismic Residential B
1PPERMITFEE Plumbing Permit P
1TRAVDOC Travel & B
Documentation
1BUSLIC Business License B