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09010005 CITY OF CUPERTINO BUILDIr;DIVISION PERMIT BUILDING ADDRESS: PERMIT NO. 22680 ALCALDE RIB FAST WATER HEATER 0 9()1 0 0()9 OWNER'S NAME: PERMIT f95UE DATE IfiSAR iE V — 1-2 6 91 1 3 2—-TvE NE A CONTROL NO. (800) 454-8955 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTORS DECLARATION Job Description m 1 by affirm that I am licensed under provisions of Chapter 9(commencing -z,j here with Section 70(X0)of Division 3 of the Business and Professions Code,and my license is "C H in full force and effect RMV/RPLC GAS WATER HEATER j aM Z License Class t te•B y t,,,p Date Contractor ARCHITECTS DECLARATION I understand my plans shall be used as public records �yU `Q y Licensed Professional 3 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the p O following reason.(Section 7031.5,Business and Professions Code:Any city or county K m which requires a permit to construct.alter,improve,demolish,or repair any structure - �? prior to its issuance,also requires the applicant for such permit to file a signed statement E_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation 3d F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or - y .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of $449 Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not more than five hundred dollars(s500). 34244019 . 0 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 Inspections and Professions Code:The Conu e actoes License Law does not apply to an owner of q P property who builds or improves thereon,and who does such work himself or thmugb 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.). ❑1,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. ❑1 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- ration,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 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 arc: 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 Icss.) 1 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.Dat^ Applicaw 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 ,J 0 forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY [~i►�-� I hereby affirm that there is a construction lending agency for the performance of 1x> the work for which this permit is issued(Sec.3097,Civ.C.) W A Lendcrs Name z Lender's Address V 0 1 certify that I have read this application and state that the above information is LL►" corect.1 agree to comply with all city and county ordinances and state laws relating to 0 U building construction,and hereby authorize representatives of this city to enter upon the m above- entioned property for inspection purposes. W W (We)agree to save,indemnify and keep harmless the City of Cupertino against to liabilities,judgments,costs and expenses which may in any way scenic against said City V Z in consequence of the granting of this permit. Date t"r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SOURCE REGULATIONS. —a - Re-roofs Signature of Applicant/Contractor Date Type of Roof HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes ❑No 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 .t hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. .strict? ❑Yes ❑No I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safcty Codc.Sections 25505.25533 and 25534.1 understand that if Use building does not currently have a tenant,that it is my responsibility to notify the occupant of the requirements which must be met prior to issuance of a certificate of Occupancy. Signature of Applicant Date All roof coverings to be Class" "or better Owner or authorized agent Date _ CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 34244019 . 00 DATE ISSUED. . . . . . . : 01/05/2009 RECEIPT #. . . . . . . . . . BS000006896 REFERENCE ID # . . . : 09010005 SITE ADDRESS . . . . . : 22680 ALCALDE RD SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER KSAR MICHAEL Y AND RENEE ADDRESS 22680 ALCALDE RD CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3977 RECEIVED FROM . . . . : JEFF JORDAN CONTRACTOR . . . . . . . : JEFF JORDAN LIC # 29100 COMPANY FAST WATER HEATER ADDRESS 12601 132 AVE NE CITY/STATE/ZIP . . . : KIRKLAND, WA 98034 TELEPHONE . . . . . . . . : (800) 454-8955 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BSEISMICR VALUATION 449 . 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 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 106. 56 VISA --------------- TOTAL RECEIPT 106 . 56 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 518 WATER HEATER 418105 Permit No: (office use only) City Of Cupertino Building Permit Application E-Mail: Buildina-Permits -,*6upertino.ora (Address is case sensitive). Jobsite Address:22680 ALCALDE RD Date: 1/5/09 Assessor's Parcel Number. 019 . 0 Owners Name: KSAR, MIKE Phone No: (408)255-1217 Project Valuation: 449.00 Building Permit info: Bida Elect Plumb X Mech Job Description Remove/Replace Gas Water Heater Contractor Information Company Name: FAST WATER HEATER COMPANY Phone No: Contact Name: Julie Caskey Fax No: 425-636-7084 Address: 12601 132ND AVE NE E-mail:carolr@fastwaterheater.com City, State &zip code: KIRKLAND, WA 98034 State Contractor's Lic. No: 877489 E xpiration Date: 5/31/10 Worker's Comp No: 1761660 Expiration Date: 12/1/08 Carrier. California State Fund City of Cupertino Business License No: 29100 Credit Card Information Credit Carl No: Expiration Date: 11/10 Name-on Card: Jeff Jordan Visa ] MasterCard ❑ American Express ❑ .. The Building permit application and a completed & signed contractorlsubcontractor form need to be submitted with each permit. Community Development 10300 Tons Ave= Cupertino CA 95014 IF Telel*one(408)777-3228 Fax(408)777-3333 CUPEkTINO B--Oc—.ng Department JOB ADDRESS: 22680 ALCALDE RD PEIUffr# n ( ER' Q OWNS NAME: KSAR, MIKE PHONE# (408)2`'515-1217 GENERAL CONTRACTOR FAST WATER HEATER COMPAf FAX# 425-636-7085 I am not using any subcontractors: _ �` l 1/5/09 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 j Glass/ Glazing Heating Insulation f I Landscaping I Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving I Plastering f Plumbing Rooting Septic Tank Sheet Metal ' f Sheet Rock Tile ., Owner/Contractor Signature Date