08030023CITY OF CUPF.RTINO
TAiFORIZMAT,Q1V
BUILDING DIVISION PERMIT
..„CO1�iTR'ACTQIi
BUILDII+Q/s 9T"MINER PL
- AFFORDABLE WATER HEATERS &
PERMIT NO.
06030023
OWNM''SVNlAMb&
PERMIT ISSUE DATE.
ft LANGEMAK JAMES G AND SUSAN A
24707 SAN FERNANDO RD
03 0 200
NE:
SANITARY NO. CONTROL NO.
ARCHr7ECT/ENGINEER:
BUILDING PERMIT INFO
REPLC WATER HEATER
BLDG ELECT PLUMB MECH
Q O O O
LICENSED CONTRACTOR'S DECLARATION
Job Description
o
men
1 hereby affirm that 1 am licensed antler n er provisioof Chapter 9 (ming
with Seetion 7001p afD,vidon 3 of Ih Basin. and Pm(euiun Cade, and my Seca h
in full force and effec !
V
Lien s Cl Lrc g
Da¢ Constraint, /
DECLARATION
As
I understand my phos shit W used as public reemt0
shall use
Licensed Pmressimad
OWNER-BUILDER DECLARATION
I hereby alum Nat 1 atm samom form the Contracmfa License Law for the
i rellowing reason. (Section 70313. Business and Pmfestion Codc: Any city nor =my
which requims a permit or comwel, alms improve, demolish, or repair any suucsure
r prior m its issuance, also requires the applicant for such permit to file. signcdstsmment
' Camracmr's1-iosomLaw
Sq. Ft. Floor Area
Valuation
that he I, licensed pursuant to Me provisions of the (Chapm9
e (commencing with Section 700M of Division 3 of the Business and Profession Code)or
!
that he h exempt therefrom and da basis for the alleged exemption. Any Nahum of
APN Number
Occupancy Type
Sccuon 7031.5 by any applicant for a penult subjects the applicant to a civil Many of
not mom Nen five hundred dollars ($500).
❑ I'm ower of Ibe property, or my employeeswith wages m theirmle mmpmaden,
Required Inspections
q p
will do the workand Man structure is out mmruled or offend formic(See. 7(MM, Busies
and Pmfesslam Code: The ContractorsUernx Law Most out apply m an Wasr of
.
property who Wildaorimprows thmmamd whodocasmhwork himselfofthreogh hu
own employees. provided that such improvemmu, see notintended oroQerd feraala U.
however. me building or improvement is sold within am year of compldden. the ewra-
builder will bow tis burden of proving Nat h did ret Wild or improve for pumom of
sale.).
❑ L u owau of the Proper• are vclmively emuau)ng with 11's— commissars an
.
conlruct the project (Sec. 70W, Busies aM Profesfiuta Code:) The U.
cense Law docs er1 apply m m owner of property who Wilds or impmves gases. W
who contracts for such pmjecu with amnuacmra) licensed punnnt m Ih Comnearfs
Lice. law.
❑ Tameaemptmder See .BAPCfor Wisaown
r Dau
WORKERS COMPENSATION DECLARATION
1 hreby steam under penalty of pe0ury one of the following declantiarre:
_
I haw and wBl mainwin. CerdBpm orCmnem is mir-Inum fw WadreraG=M-
an., u M,i&d for by Sauan 3700 of the IAbor Cade, f n dm performuc of Ih
.
work for which this Mrmil is issued.
❑ I have and will maintain Workeh Compensation Insurance, u required by Stadm
3700 of Ne labor Code, for Ne performance of Ne work for which this permit h immd.
My Workers Compensation Insurana carries arsd Policy number am: 6%Q
2&5
Cartier. Ze.av-/•i' Policy No.: Z-04
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(7Th shim need ml W complied If the permit Is foram hundred dollars(S100)
or leas)
1 comb Nat in the performance of Ne wort for which this pcmi, is issued, ) shell not
employmy person inmy manrerso as m become subject to the Wartcn' Campemaded
'
Laws of Califamia. Date
Applicant
'
NOTICE 3O APPLICANT: IL ager making this Certificate of Exemption. you should
become subject m Ih Workces Compensation provision of she Lehr Code you mad
r forthwith comply with such provision or this permit shall W deemed ranked.
CONSTRUCTION LENDING
ngAGENCY
Nes More i... gcoq
agency for the perfuman¢ of
I hor
Cing
which ed (Sec. M.
y duh (ser which nth pcmit is issued (Sec. J09t, Cir. C.)
Le
lender's Name
� lenders Address
1 comfy mal I have read this application and sure mal me move information is
" camel, 1 agree to comply with all city and county ordinances and sum laws miming to
building convection, and hereby authorim representatives of this city to enter upon the
urpoes-
move.mentioned propcny for inspection purposes-
4
(We)agree to save, indemnify and keep harmless the City of Cupertino against
(Wo) agree
0 liabilities, judgments, costs and expert which may.. any way scene aphou(said 01,
7 in of
-�' APPLICANT Ufmc gm Ang
NDrmu CO PLY WITH AL NOttfjjf...POfNT
Issued by: Date,WST
'
SOURCE LATIO G / s.
/ o
Re-roofs
Type of Roof
Signawrc afA rpDam
US MATERIALS DISCLOSURE
HAZARDOUS
WIIl the applicant or forum building or handle heafts"Safely
u htiSed by the Cupertino Munici i Coda Chapter 9.12, aM dm H®Ire and Safety
otic, Section 25532(x)?
All roofs shall be inspected to any roofing material being installed.
❑Yu No
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will me applicant or future building occupant use equipment or devi es which
cmlt It ... rMas aircnnuminnta as by the Bay Ana Air Quality Mmagcmcm
all new materials for inspection.
Dimia?
❑Yu No
1 have road me Imardus maerialsnquinments undmChapmr6.95 alum Calera-
me Health 6 SdayCedc, S,:cuons255()s,25533 and 25534.1 undcrsund thatif gm Wilding
does not currently have a ¢nano m t1 my responsibility m rwuty me Mannar, of dm
ayuircmcnta wnim�w.y�t rmixivanrc era cadre,-le�rr"�`�
Signature of Applicant Date
All roof coverings to be Class 'B" or better
.1Dam.
Overawe/m /<`/nt
• 4 ITEMS OF 32
L
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 31626076.00
DATE ISSUED.......: 03/06/2008
RECEIPT #.........: BS000004096
REFERENCE ID # ...: 08030023
SITE ADDRESS .....: 10164 MINER PL
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: patg
COPY # : 1
VOICE ID DESCRIPTION
-------- ----------------------------
518 WATER HEATER
VOICE ID DESCRIPTION
------------------------------------
OWNER ............:
LANGEMAK JAMES G AND SUSAN A
ADDRESS ..........:
10164 MINER PL
CITY/STATE/ZIP ...:
CUPERTINO CA, 95014-2202
RECEIVED FROM ....:
EDDIE D 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
----------
1BSEISMICR
-----------------------
VALUATION 950.00
------------------------------
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
VOICE ID DESCRIPTION
-------- ----------------------------
518 WATER HEATER
VOICE ID DESCRIPTION
------------------------------------
0
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SRI-
C
Clio OFUPEQilN0
CITE OF CUPERTINO
WATER HEATER
PERMIT APPLICATION IFORNM[[
OM(DoL5
A.PN # (6 O
(o2—(PC
Date:
Building Address:
PL -
Owner's Name:
Phone #:
Dc,V a'
Llof- 6- 'q- 7k4v
Contractor:
Phone #: 6 6:1- .1 Sri - 713 1
,Affordable. WOer
-q-
Fax #: bbl -J5 (-
Cupertino Business License #:
Cupertino
Contractor State License #:
.16 8'SD
6-7368
Contact:
Phone #: 1041 -,glj - 0 5'd- D
Scott Litfil�Fielcl
Pax#: (obt-.3 Sy-gssb
Building Permit Info:
Bldg ❑ Elect Plumb
Mech 0�
Residential N]
commercial ❑
Job Description:
14 PIC-ce- vico-2r 14- �e-r
Strapped Ff On Platform ❑ Bonded 5d"�
New Location ❑ Replacement
Valuadon:
q5D—
Green Building Check must be completed and attached to this application.
Green Building Points achieved:
CITY OF CUPERTINO
WAFER HEATER
• CUPERTINO PERMIT APPLICATION FORM
C`
Quantity
I Fee ID
Fee Description
Fee
Group
Permit Type
IPCWHEATR
Commercial Water
HeaterNent
B
PCWHFATR
BSEISMICOM
Seismic Commercial
B
1 PRWHEATR
Residential Water
Heater/Vent
B
w PRWHEATR
BSEISMICRE
Seismic Residential
B
PPERMITFEE
Plumbing Pernut
P
1
TRAVDOC
Travel &
Documentation
B
BUSLIC
Business License
B
E
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
PERMIT a �- pp2
OWNER'S NAME: W v m L'A" e n^R
PHONE # efa - Sb q'— '79- V
GENERAL CONTRACTOR: Afferoagi.. 1 ,
FAX # & eP-
I am not using any subcontractors: 1 � OC/ ✓ 316 4,a -
Signature Date
Please check applicable subcontractors and complete the follnwinv infnr nfinn-
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