07030043 CITY OF CUPERTINO "
`BUILDING DIVISION PERMIT � ' ' � ® ZRM�TT� '
BUILDING ADDRESS: PERMIT NO.
22621 POPPY DR BETTER NATER HEATERS 07030043
OWNER'S NAME: PERMIT ISSUE DATE
PAVIC MARY A AND ZELJKO 351 FALCATO DR. 03/07/2007
ONE: SANITARY NO. CONTROL NO.
(408) 25 )-6672
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLCDG, EO PWW ME�CH
op LICENSED CONTRACTOR'S DECLARATION Job Description
V P I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of the Business andp{oCt arc,and my license's REMOVE X REPLACE WATER HEATER
y in full force and effe �f 11(1�
r rJ? License CI Lic.#
La Date Contractor -
ARCHITECTS DECLARATION
i a< I understand my plans shall be used as public records
y U
C.H Licensed Professional
'y� OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
p 00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
<,�,V which requires a permit to construct,alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to rile a signed statement Valuation
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 3q.Ft.Floor Area
r F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $1600
i that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of A�tq�tT Number Occupancy Type
not more than five hundred dollars($500). 3421209L .
V V
0 1,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,Business Required fired Ins ecti ons
and Professions Code:The Contractor's License Law does not apply to an owner of q p
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
salt.).
as owner of the property,am exclusively contracting with licensed contractors to
nstroct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense raw does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
Iidnse Law.
I am exempt under Sea B&P fo this n
f-43-A.14 CT Owner '—l
�C Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code•for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number ate:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z " CONSTRUCTION LENDING AGENCY
(~-a►�- 1 hereby affirm that there is a construction lending agency for the performance of
Qui the work for which this permit is issued(Sec.3097,Civ.C.)
a Q Lender's Name
Lender's Address
U O I certify that 1 have read this application and state that the above information is
41. . correct.I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City or Cupertino against
1_4(/I liabilities,judgments,toss and expenses which may in any way accrue against said City /
U Z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by
CATION L J 7
/ Re-roofs
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino unicipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs ;hall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future building occupant use equipment or devices which
If a roof i;installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Yes Nu
1 have read the hazardous materials requirements under Chapter 6.95 or the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
rc uircmcniswhichmust be�;;Vprior toissuance ofaCcruPateor eupan�y. Signature of Applicant Date
rt- r� All roof coverings to be Class "B"or better
Owner or authorized agent Date
CITY OFCUPERTINO
WATER HEATER J�30a+->
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
7 /7
r
Building Ad�dreess: 3/
6� 2-
Owner's Name:Owner'sName: _ Pho e#:
Gge zS' 2 z 76
Contr r: honc: License#:
Contact: Z
Phone:
Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job DesciptirResidential
Commercial ❑
Cost of Project:
Strapped On Platform Bonded
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER eater Heater/Vent BUILDING
PPERMTTFEE Flumbing Permit Issuance PLUMBING
BENERGY 1
Energy BUILDING
BUSLIC E-usiness License BUILDING
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: kiersaw
COPY # 1
Sec: Twp: Rng: Sub: B11: Lot:
APN 34212091 . 00
DATE ISSUED. . . . . . . : 03/07/2007
RECEIPT # . . . . . . . . . : BS000000622
REFERENCE ID # . . . : 07030043
SITE ADDRESS . . . . . : 22621 POPPY DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : PAVIC MARY A AND ZELJKO
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : CUERTINO CA, 95014-0802
RECEIVED FROM . . . . : RECEIPT INTERFACE
CONTRACTOR . . . . . . . : FR:XNS CARTWRIGHT LIC # 26514
COMPANY . . . . . . . . . . : BETTER WATER HEATERS
ADDRESS . . . . . . . . . . : 35L FALCATO DR.
CITY/STATE/ZIP . . . : MI!IPITAS, CA 95035
TELEPHONE . . . . . . . . : (4 )8) 250-6672
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 REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 84 . 02 VISA
---------------
TOTAL RECEIPT 84 . 02
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- -----------
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING