06020053 CITY OFCUPERTINO dg.,�ry 'Ifi •�'"��° ' 7 '• `��
BUIING DIVISION PERMIT �,d,NT12.ACT(1R T1OtMA"CION• :
LD
BUILDING ADDRESS: AFFORDABLE WATER HEATERS & FERMITNO.06020053
7855 CREEKLINE DR
R'S NAME: PERMIT ISSUE DATA
SIMON HO 24707 SAN FERNANDO RD 02 09/2006
PHONE: SANITARY NO. CONTROL NO.
(661) 259-7131
ARCHITECIENGINEER: BUILDING PERMIT INFO
BLDG ELECT t� PO O
�oo LICENSED CONTRACTOR'S DECLARATION Job Description
.g du 1 heroby afllren Net I am licensed under provisions at Chapter 9(commencing
with Section 701X1)d Division 3 of the Business out Professions Code.and my license is
n� in tit ndeIt �. 2 6f( REPLACE 50 GAL WATER HEATER
vii Z License Clu _ Wc.N
n
Data C S D12L rD 4s. Za
As shall use DELLA r ION
1 understand my plea shell M mW a public records Xnn
7 V
+k.ij Licensed Professional
M V
OWNER-BUILDER DECLARATION �U
q 1 Mushy arilam on 1 em exempt from the Cssions Co License Lew far the /
O O fallowing moon permit
t 7(131.4 t,star. and improve,
dca li Calc:Any Illy at county
$ which its too a permit re ems;the stet improve,demolish,or repair any.traemm 8 O O
—� that Wo,toitspe sedpulow mquime aro applicant of forthe sucContravenes
Li ...eLnedatRmmcb
c momeknmaua puamanl m Nc of Division
of Nc canuumrlli enmiaw(Cnepmr9 Sq.Ft.Floor Area Valuati
Il$ (commencing with Section Wife)of Divbianl of the Business and Rofra:itm Code)ur
a that het,exempt therefrom and do bub for the alleged exemption.Any violation of
Section 7031.5 by any optimum for a permit subjccls Ne apPlianl o a civil penally of r Occupancy Type
not some Nan Ove hundred dollars(550)1.
❑Las owneroflhe property.mmy employees with waguudchsoleeompeuedon.
untie Naffteolmrku Codee�The ca�d:aar u�La does,se apply e'�'-or Required Inspections
property who builds or improves demon.end who Marotta wark himeel f or through his
awn employee,provided Nn Ruth improvement,am notimmnded ostriches forsele.If.
however,the building or Improvement is old within aro year of completion the owner.
b trim,will Mw the burden of proving that he did net bund or improve for purpose of
ale.).
❑1,u owner of the property.am eclusively contrseling with licensed commumars o
construct the projed(Sec.7044.Business and Professors Code:)The Contracmr's LI-
ceue Law data not pply to an owner of propeny.who Wilds or improve,themtn,and
who convects for such projects with a commdor(s)tionsed punuent be the ConumtaYa
License Law. .
❑Iarecomplunder Sec. ,Bk PCfosthbmason
r Dem
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury ane tithe following dalmatians:
❑I toward will mainuin.CmlOamof Cmnentoulf-Imumfor Worke Cmnpcn.
action,u pmvidcd for by Sadon 3700 of the Labor Code,for It p ufonamme of the
work for which this permit is issued.
❑I haw and will maintain Workers Compensation Inman¢,an required by Section
3700 of the L&Wr Code.for the performance order work fa which this permit is Issned.
My Carrier. r�CN otnlumnce ani,,Policy No n rye 9� )
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This=am need nal W completed itdo permit Is form hundreddolWa(SHXE
or leas)
1 cenriy that In the wrloorma a of Ne wad fm which this permit is issued.I atoll not
employ any person In my manner an u be become object an the Worker'Compemation
Levee of Califantla Dem
Applicant
NOTICE TO APPLICANT:If,after making this Ceninete of Exemption.you should
become object to Ne Worker Compensation provisions or the labor Code,you most
�Z forthwith comply with such prevision or this permit hall W seamed rewkcd.
.z„y CONSTRUCTION LENDING AGENCY
[—r I hereby affirm that them is A convection lending agency for the perfurmnm of
y'> the work for which this permit Is Issued(Sri.3097,Cl,C.)
GQ Lenders Name
D z Lender's Address
V Q 1 century that I hew read this application and sum that the show infamous Is
LL F correct 1 epee antimatter comply with all city and county antier and auk laws ralating o
0kbuilding consimcdon,and hereby othadre ramcamutives of this city Mannar upon the
U above-mentioned properly for IMPection purposes
gy (We)Agree to naw,indemnify and keep harmku tie City of Cupertino agalut
CAI lie bili du,judgments.esu Rodexpersa which may in my way acerae Against sodCity
fJ 7 inneE
m{of Nis Il
C
LICA ANDS A I COMPLY WIT aSL.NO—INT Issued by: Date
SOUS. / 4 Re-roofs
dCanuactar the
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will do applicant or f rou,Wilding occupant,sloe or Ianue hazardous material
Vdenrmd by the Capsula Municipal Cade.Chapter 9.I,and the Hush and Safety
k.Sectim:553x(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yta on
Will the applicant or robot Wilding occupant um equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
emh hevadnus air canumirsnts u dcMcd by Ne Bay Arca Air Quality Management all new materials for inspection.
District?
[3 Yes 131fu
I haw mad the haardws materials requirements underCWper 6.95 or the court.
nu Health @ SafetyCode,Sections 15505,15533 and 25534.1 undmseard that irtim building
does not currently,h ant,that II is my rerpankle I I.ty se newly dm oecupnt of the
mgmremm is m t mel tsar olssanecallcofficam or Occupgn�.��/ Signature of Applicant Date
Owner or eutharived ant ?//tam h All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
,' ✓ Cupertino CA 95014
Telephone(408) 777-3228
IOUPE(�TINO Fax(408)777-3333
Building Department
JOB ADDRESS: 785"5' C r<e4- '-t w� 't;>9— PERMIT #
d 6 a 2�o s-3
OWNER'S NAME: 51 n.c N 44c> PHONE # 2$a -g-b zs
GENERAL CONTRACTOR rDA81�rw#) .A,� FAX # /
I am not using any subcontractors: (;2� ns Y z
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
• CITY OF CUPERTINO
Item 3 Of 5 PERMIT RECEIPT OPERATOR: suem r
COPY # 3
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36217045.00 ,
DATE ISSUED. . .. . . . : 02/09/2006
RECEIPT #. . . . . . . . . : 33152
REFERENCE ID # . . . : 06020053
SITE ADDRESS . . . . . : 7855 CREEKLINE DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : SIMON HO
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4155
RECEIVED FROM . . . . : EDDIE NALLEY
CONTRACTOR . . . . . . . : LEONCE ROUX LIC # .26850
COMPANY . . . . . . . . . . : AFFORDABLE WATER HEATERS &
ADDRESS . . . . . . . . . . : 24707 SAN FERNANDO RD
CITY/STATE/ZIP . . . : NEWHALL, CA 91321
• TELEPHONE . . . . . . . . : (661)259-7131
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
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
CITY OF CUPERTINO
WATER HEATER _
CUPEkTINO PERMIT APPLICATION FORM a�oa dos 3
APN# / Date:
Building Address:
X855 C�ee�,li�e Dr•
Owner's Name: Phone#:
Sir,.or I+o q0 - aS� $u
Contractor: Phone: (.-W License#:
jgffardWe- o, e ecre.rs 8,S1 .113 ) (0010 310e
Contact: Phone: (obi Cupertino Business License#:
colT L-i1T &4e J 5 P540 �gSo
Building Permit Info:
Bldg ❑ Elect Er Plumb Mech E'
Job Description: Gas
gePIGce. So woer NeaTer CSAme Joe-ar-'on
Residential Commercial ❑
Cost of Project: Goo
Strapped On Platform El Bonded 13-
•I New Location ❑ Replacement ES
Qty. if
Applicable Fee ID Fee Description Fee Group
i BPWHEATER Water Heater/Vent BUILDING
PPERMPTFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
•