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06100068 CITE'OF CUPERTINO 77777777777-1,.., BUILDING DIVISION PERMIT .. Zoi RM TIN. BUILDING ADDRESS: PLUMB IN TIME INC PERMIT NO. 06100068 19624 HOMESTEAD PERMTT ISSUE DATE OWNER'S NAME: KEN ROBINSON 360 MEM NE: SANITARY NO. CONTROL NO. (866) 293-3031 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG EO PLUMB MECH O p LICENSED CONTRACTOR'S DECLARATION U3 I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description zwith Scction 7000)of Division 3 of the Business an r f ns Codc y license is y in full force and effect f (' REPLACE WATER HEATER 40 GALLON GAS License ass Lic.# t-w Date Contractor 6LC ARCHITECTS DECLA ATION ode< I understand my plans shall be used as public records ryU G y Licensed Professional t y W OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractofs License Law for the :00 following reason.(Section 7031.5,Business and Professions Code:Any city or county 3.9 which requires a permit to construct,alter,improve,demolLch,or repair any structure 20 prior to its issuance,also requires the applicant for such permit to file a signed statement x c that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation t-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or .. 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 TAWN&&& 0 0 Occupancy Type not more than five hundred dollars(5500). ❑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,Business Required Inspections 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 sale.). ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- cense law 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 License Law. ❑I am exempt under Sec. B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: I 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 wo"r which this permit is issued. ❑I 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. a W r rep sa�tion Insu n carrier aqd Policy n}tmbc are' ��1�/ -L/✓�� C(1/rtTNQ�feNf✓/ 7GCERTIFICATE F EXEMPITON FROM WO RS' f4�f'f-'C�fAto1PENSATION 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,1 shall not employ any person in any manner so as to become subject to the Workcrs'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 Z forthwith comply with such provisions or this permit shall be deemed revoked. O CONSTRUCTION LENDING AGENCY [~.r I hereby affirm that there is a construction lending agency for the performance of 9i> the work for which this permit is issued(Sec.3097,Civ.C.) W A Lender's Name aZ Lender's Address U C I certify that I have read this application and state that the above information is IL r-" correct.I agree to comply with all city and county ordinances and state laws relating to 0U building construction,and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. W (We)agree to save,indemnify and keep harmless the City of Cupertino against ,.4 liabilities,judgments,costs and expenses which may in any way accrue against said City V in co nee of thegranting of is permit. Data ►^� PP C NT UNDERSTA AND WILL COMPLY WITH ALL NON-POINT Issued by: C ULATION . �O Re-roofs Signa of Applicant/Contractor Date HAZARDOUS MA LS DISCLOSURE Type of Roof Will the applicant or future building pant store or handle hazardous material as defined by the Cupertino Municipal Co Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Ycs _-ET9o If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminan�lined by the Bay Arca Air Quality Management all new materials for inspection. District? ❑Yes ❑No I have read the hazardous materials reyuircmcros under Chaptc :h5 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.1 unde d that if the building j�� e a tenant,that itis my responsibility t otify the occupant of the ust be me r ip i uance of Ica j7Ekup Signature of Applicant Date / v - owne or thorircd agent Date All roof coverings to be Class B or better Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CIN OF Fax(408)777-3333 %HkTINO Building Department JOB ADDRESS: I n' ^n� JM . PERMIT #y ^� OWNER'S NAME: lY L- PHONE #l•/Vl _� 3 GENERAL CONTRACTOR- ►n l FAX # am not using any subcontractors• J �r 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 e Contractor Signature Date CITY OF CUPERTINO _ Im 1 of 1 PERMIT RECEIPT OPERATOR: amyw COPY # 2 Sec : Twp: Rng: Sub: Blk: Lot.: APN . . . . . . . . : 31605047 . 00 DATE ISSUED. . . . . . . : 10/10/2006 RECEIPT # . . . . . . . . • : 36377 REFERENCE ID # . . . : 06100068 SITE ADDRESS . . . . . : 19624 HOMESTEAD RD SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : KEN ROBINSON ADDRESS . . . . . . . . . CITY/STATE/ZIP . . . : , RECEIVED FROM . . . . : PLUMB IN TIME CONTRACTOR . . . . . . . : PAUL HENDRIXSON LIC $# 27607 COMPANY . . . . . . . . . . : PLUMB IN TIME INC ADDRESS . . . . . . . . . . : 360 MEMORIAL DR STE 140 CITY/STATE/ZIP . . . : CRYSTAL LAKE, IL 60014 TELEPHONE . . . . . . . . : (866) 293-3031 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 NUMBER - - -- - --- - ------- - ------ ----- - --------- --------- CHECK 84 . 02 1002 TOTAL RECEIPT 84 . 02 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- --------------------- 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING 3Sys 6yob S� 6635 Cf'fir+« �,�Y HNO 0� .E ., i PEN- , Li �r�.'� t�� c�� APID �� � r ' Prf . -11,0N � L Lk J14ci s Name ST e �Qnn i \fie n e Cor�ir4cto�-_ L T-Ll 13) 6 - t �-iCense n: cuperc ino Business J.icerisc n: ,, V ^ ilii. P er�niti Info: , f B'-a-15 Elect -100 Descrlptmn: cin i C�32mc-' a,1 f ! i � it s �osT O? pe©jcC . �- S 5 oOil Platform El 1 Bondcd Li p3acernei4� i Appligable Fee CD FCC Descrlpptloae i ATER F/t� � � ­- dee�rc�� EP� Tfi ut�ae�!�� ✓cgPif y TY LDFNIG cl BUILSJ"�V -- BUILDfNG 1 ! ` ` )me a` o V4