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06030184F_ L 0 zz� WQ D UO_ OF U W U� CITY OF CUPERTINO +ss.�'3 BUILDING DIVISION PERMIT �CO£tITRACTOR INFUIiMATIU angY.� ,,.a.Ysaxt,y Iii a:.gyl', ry%*ae� BUILDING ADDRESS: ts PERMIT NO. 21572 COLUMBUS AV WNER'S NAME: PERMITISUEDATE FUJIKAWA BRUCE Y AND KATHL N Y3345 SELDON CT 03/31/2006 HONE: SANITARY NO. CONTROL NO. (510)376-4816 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECN LICENSED CONTRACnOWSderp DECLARATION Job 1 the I w Bayed under nr Chapter 9 (commencing that and Profmn with section7M) Division 3orthe Business and Profcudnns Code, andmylicense is ion 7 ) of WATER HEATER REPLACEM T LEp in tun force and effect. 9' 90 est Uc.• DamClea Date "� '--3 / _ OG Contractor/ 1dt APR I7— 700Q RATI ARCHITECTShe DECWON iundcrwnd my plan stillmuudupmNk records ti Licensed loom OWNER -BUILDER DECLARATION ��' I herebyaffirmthat 1 am exempt (rum Mm Contractor's License Law for the �� following reason. (Section IID 1.5, Bualness and Prolosshms Cod.: Any city or worry C• $950 which royal. a Peresit1. consumer, after. Improve, dmunlsh, or repair any ma cture prior to is issuance, also requires the applicant for such Permit to rile a signed statement that m is licensed pursuant m the prevision of mcc Contractor's Ucense law(Chaptcr 9 Sq. Ft. Floor Area Valuation (commencing with Section 7000) of Division 3 of Me Business and Profusions Cuda) or that he is attempt therefrom and Me buds for Ne alleged exemption. My violation of 7llPlqYuih6eir Occupancy Type Section 7051.5 by any applicant for a permit subjects Bon applicant m a civil penalty of trot more than rive hundred dollars (SSW). ❑ 1, as owner of the p epeny, or my employees with wage, u their sole Compensation, Required Inspections will do the work, and the structure is not intended or offend for sale 7044, Business and Premodern, Code: The crruscwr, uamae Law dors rat apply W an ove=r of property who builds or improves thereen, and who dassuch work himself or through his own employmes, provided that such impnevemens arc not Intended m offered for ole If, ' however, Ne building or Improvement is veld within oa year of completion, the ow=r- builder will have Me burden of proving that he did not build or improve for purpose of ❑ 1. as Owner of Me propeny, am exclusively contracting with licensed conmacmra to construct the project (Sec. 7044, Business and Profession, Code:) The Commutes Li - come law dace not apply b an Owner of property, who builds or Improves Morocco, and, who commesfor such projects; with contramoMs) licensed pu munt m the Conueclor• License Law. lam attempt under Set ,Bd PCforthsnaen Date ocaner WORKERS COMPENSATION DECLARATION 1 hereby elbow under penalty of perjury oa of the following declarations: ❑ 1 have and will maintain aCert lands of Coma, m self-imur, fa WOrteesCmnpon- sNon, as provided for by Section 7700 Of Me labor Code, for the performance of tite work for which this Perms is issued ❑ 1 have and will maintain Workers Compensation Insurance, as required by Section 37M of the Leber Code. for the performance of the work fro which this permit is issued. My Woaces Cumperuation Iruunnce Cartier and Policy number am: Cartier:Policy No, CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This salon need not becmmplem l ifthe permit Is faro= hundreddolims (5100) or Was) 1 amity, that in the performance of the work for which this permit is load, I Nall nm employ any person in any mama rso as an become subject to Me Worken' Compeuada Laws.f California. Dan Applicant NOTICE TO APPLICANT: IL after making this CeniOcate of Exemption, you Mould became subject be the Wormes Compewdon provisions of the lab=Code, you mus fothwith comply with such proviMms or this Permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that Men its eemwctdon lending agency for Me Perfmmmee of the work for which this Permit s Ivu.d (Sec. 3097, Civ. C.) Undoes Name , Unders Address I awry that 1 haw mw this application and este that the Mme inromtation is correct. 1,grac to comply with all city and county oMnanas and state [am relating to building convection, and hereby ammrin ropresentadver of this city to enter upon the ahow-mentioned preperty for inspection purposes. (We) agree to mw, indemnify and keep harmless the City of Cupertino •gainsl liabilities. judgments, costs and expenses which may In my way acme against said City in Por da, of Ceame, WILLMIL APPLICANT UNDERSTANDS WILL COMPLY WITH ALL NON -POINT AND Issued by: Date SOURCE REGULATI Re -roofs Type of Roof _G S,jnmur6�AppltesHDem HAZARDOUS MATERIALS DISCLOSURE WilltheftCieantor(stun Wilding occupant handle u defined Chant,mmor Cupertino Municipal Cade. Chapter 9.13, and the Hcaith and Sefcty Health and ewe, io 25 All roofs shall be inspected prior to any roofing material being installed. I-]Y.2ss3z(a>? I-] Y. f$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'.vier which emit havarlou Mir canmminans u Mfincd by the Bay Area Air Quality Management all new materials for inspection. District? ❑Ye, _IQ NO Ihaw mad the h®,mous materials mptimmens underChapter 6.95 of me CaRfrr k� ria Hui" Safely Codc, S.edo s 25605,25533 and 25534.1 understand thm ifM a building does an currently haw a tenant, that It s my rupnnaihiliry te notify Me occupmt of the requiremcnuwhrehtxMet pdormlsavanaare Certificate ofpumy. Qem Signature of Applicant Date _ �*� All roof coverings to be Class "B" or better Owner tar omhadxel agent Dam Sm 2 of 2 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 35618056.00 DATE ISSUED.......: 03/31/2006 RECEIPT #.........: 33810 REFERENCE ID # ...: 06030184 OPERATOR: amyw COPY # : 2 SITE ADDRESS .....: 21572 COLUMBUS AV SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OWNER ............: FUJIKAWA BRUCE Y AND KATHLYN Y ADDRESS ..........: CITY/STATE/ZIP ...: CUPERTINO CA, 95014-4711 11 RECEIVED FROM ....: ALL VALLEY PLUMBING CONTRACTOR .......: MARY SANDBRINK LIC # 23015 COMPANY ..........: ALL VALLEY PLUMBING ADDRESS ..........: 3345 SELDON CT CITY/STATE/ZIP ...: FREMONT, CA 94539 TELEPHONE ........: (510)376-4816 • FEE ID ----------------------- UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL 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 ---------- ---------- 49.16 0.00 ---------- ---------- 49.16 0.00 METHOD OF PAYMENT AMOUNT ----------------- NUMBER CHECK ------------ 98.32 ------ - ----------- 7094 TOTAL RECEIPT 98.32 VOICE ID DESCRIPTION VOICE ID DESCRIPTION 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING 11 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Buildin De artment JOB ADDRESS: /� PE o6 OWNER'S NAME: z5'aga IJ.t_- GENERAL CONTRACTOR./ -+t (v FAX # I am not using any subcontracto mue Date vnel rmP fnllowinQ information: 1"1C<ISC 11lCU� n ua.aavac vuan.v.•.a.. 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 rc Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: / 6 7 C�u�J PERMIT # 06030 1 �� OWNER'S NAME: teQIJeL PHONE # U U GENERAL CONTRACTOR: t ( vett FAX # I am not using any Please check applicable Signature Date and complete the following information: Owner/ Contractor Signature Date 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 I • CITY OF CUPERT O 000 WATER HEATER ri IPFRTINO PERMIT APPLICATION FORM APN J- d Da[e: Building Address: AP�572 WUM69, h" S Owner's Name: Brace f',u; kaWq iJ Phone #: 40� ,�? v lvy5l8 Contractor: License #: ef 6' q Contact: Pho #: y , 6 r ,e'S/ Applicant/Contractor: Building Permit Info: Bldgum Job Description: .urea Toru �r�A«.. w+wr� esidentt : Commercial: Sq. t. Floor Area: $/Sq.Ft.: Architect/Engineer: Valuation: %30 -to Type of Construction: Occupancy Group: Qty, if Water Fee iI rrtxmfi lr ✓E Plumbing Permit Issuance PLUMBING