06060065 7 777,17 7 777:
C"TY OF CUPERTINO .......... ..........
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PLUMB IN T IME ,INC PERMIT No.06060065
23057 CRICKET HILL R
PERMIT ISSUE DATE
OWNER'S NAME:
RIPAN NAGPAL 360 MEMORIAL DR STE. 140 0610812006
SANITARY NO. CONTROL NO.
vE:
(866) 293-3031
BUILDING PERMIT INFO
ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH
ce
p Q LICENSED CONTRACTOR'S DECLARATION Job Description
U C I hereby affirm that I am licensed under provisions of Chapter 9(commencing
z E with Section 7000)of Division}of the Business and oy{Coda ertsc is
>>y in full force and a pct (/yam (S/C REPLACE HOT WATER HEATER 40 GAL GAS
v�z License CI Lle•#
t—a Dam — Contractor
RCHITECTS DECLARATION
i a< 1 understand my plans shall be used as public records
iyU
m y Licensed Professional
y
OWNER-BUILDER DECLARATION
s I hereby affirm that I am exempt from the Contractor's License Law for the
j00 following reason.(Section 7031.5,Business and Professions Code:Any city ler county $500
m 9 which requires a permit to construct,alter.improve,demolish,or repair any structure
t"y prior to its issuance,also requires the applicant for such permit to file a signed statementValuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
H (commencing with Section 7000)of Division 3 of the Business and Professions Codc)or
r3. that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of AFNI 14MA36r U Occupancy Type
not more than five hundred dollars(S500).
0 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 Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or trough 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.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The conractoes 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.
0 I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
tJ I have and will maintain a Certificate of Consent to self-insure for Workers Compen.
sation,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 Workces Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Warkes Com on Inau ce artier andel Policy no be arq;?-/ /
ER77FICATE OF EXEMPTION FROM WORKERS'
✓rA l _COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
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.Date
Applicant
NOTICE TO APPLICANT:if,after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Code,you must
,Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
('~.a I hereby affirm that there is a construction lending agency for the performance of
G�. the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lenders Name
Lenders Address
U 0 1 certify that I have read this application and state that the above information is
US 0- correct.I agree to comply with all city and county ordinances and state laws relating to
0 Ubuilding construction,and hereby authorize representatives or this city to enter upon the
UWabove-mentionedproperty for inspection purposes.
GL (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
V z 'n consequence of the granting of this permit Date v
PLI UNDERSTAND -AND WILL COMPLY WITH ALL NON-POINT Issued by: -a
ULA NS. ,�
(/ Re-roofs
ignat of Applicant/Contractor Dam T of Roof
HAZARDOUS MATERIALS IS O1 Type
Will the applicant or future building occu ore or handle hazardous material
as defined by the Cupertino Municipal Code,Chap r 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Q Yes B r+o
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 contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? /
Yes Bt1.
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Cade,Sections 25505,25533 and 25534.I understand that if the building
d my have a tenant,that it is my responsibility to notify the occupant of the
me which must be met bu issuance of a Ce ' ate of Qccu ape Signature of Applicant Date
[/ All roof coverings to be Class"B"or better
caner o a ®rived agent Dam
Community Development
t 10300 Torre Avenue
5a Cupertino CA 95014
Telephone(408)777-3228
CIV OF Fax(408)777-3333
�MkTINO
Building Department
JOB ADDRESS: PE I # a 0
OWNER'S NAME: PHONE # ZSR
GENERAL CONTRA TOR: — AX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followin ormation:
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
,m 4 of 4 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 34241035 . 00
DATE ISSUED. . . . . . . : 06/08/2006
RECEIPT # . . . . . . . . . : 34747
REFERENCE ID # . . . : 06060065
SITE ADDRESS . . . . . : 23057 CRICKET HILL RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : RIPAN NAGPAL
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 336 . 08 23377
TOTAL RECEIPT 336 . 08
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-----
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
i
t" CITY OF CUPERTINO
NATER HEATER
CUA j k7INO PERMIT APPLICATION� A7['ION FORM
FAP: t 3 —` v t
(� Date:
Buil4g Address: 5 6
Owners Name:
Phone #:
`� ah a,1 0 - S
Contractor:
License#:
COnta(t:
Cupertino Business License #:
Building Permit Info: i`
i
Bldg ❑
Elect Plumbl� Mech
Job Description:
Res1d6ntialO
i
Commercial ❑
Cost of Project: _
Strapped ® On Platform Bonded
New Location
Replacement
i
Cty-i if
Appli able Fee ID Fee Description Fee Grou
BPWHEATER Water Heater/Vent p
PPERA41TFEE BUILDING
Plumbing Permit Issuance PLUMBING
BENl1RGY Energy
BUSLIC BUILDING
Business License BUILDING
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