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07080052CITE- OF CUPER-1 If BUILDING DIVISION BUILD 11G6j�Q,R _SS:M I RA OWNER'S NAME: XIAO HUANG ARCHITECT/ENGINEER: PERMIT VISTA AV LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing vith Section 7000) of Division 3 of the Business ions C �d my license is n full force and effet -icensc Class a••� [.ic. # . S'ate S!' Contractor -�—� #ARCHITECTS DECLARATIO I undcrstand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county 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 that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he i§.exempt therefrom and o(a az °r the ° subjcclleged is the applicantto a civiln. Any tolation of pcnalty of Section 7031.5 by any applicant pe not more than five hundred dollars ($500). ❑ I, nowner of the property, or my employees with wages as their sole compensation, will dti tare work: and the structure is not intended or offered for sale (Sec. 7044. Business and Professions Code: The Contractor's License Law docs not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, in that such improvements are not intended or offered for sale. If, however, dme 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 ContraMes Li- cense Law docs 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' , B & PMO on ❑ I am exempt under ec r y Owner W RT. 'S O ENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: �] 1 have and will maintain a Certificate of Consent to self -insure for Workees 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 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 Workers Compensation Insurance carrier and Policy number are: :artier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE PLUMB IN TIME INC 360 (866)293-3031 PERMIT NO. 07080052 PERMIT ISSUE DATE CONTROL NO. BUILDING PERMIT INFO ELECT PLUMB Job Description REPLACE WATER HEATER, 29 GAL GAS. (This section need not be completed if the permit is far one hundred dollars (31110) rr less.) certify that in the performance of the work for which this permit is issued. I shall not :mploy any person in any manner so as to become subject to the Workers' Compensation aws of California. Date 4pplicanl 140TII;E TO APPLICANT: If, after making this Certificate of Exemption, you should accolile subject to the Worker's Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (See. 3097, Civ. C.) Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. 1 agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. (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 in consequence o c granting of this permit. APPL A NERSTANDS AND WILL COMPLY W ALL NON -POINT SOUR G ATIONS. t Ax Si ature of can/Contractor Date HAZARDOUS MATERIAL SCLOSURE Will dte applicant or future building occup t stare or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)7 ❑ Yes /fi No 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 District? ❑ Yes 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building docs- t currently have a tenant, that it is responsibility to notify the occupant of the requv cn is mull be met prior u cc r. C ate of Occup CK'ner or auth zed agent Date L Ft. Floor Area 3570203: AR Num Issued by Re -roofs Type of F.00f valuation $700 Occupancy Type Required Inspections All roofs shall be inspected prior to any roofing material being installed. If a roof : s installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signatur( of Applicant Date All roof coverings to be Class "B" or better 3 ITEMS OF 3 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 35702032.00 DATE ISSUED.......: 08/07/2007 RECEIPT #......... BSC00002280 REFERENCE ID # ...: 07C80052 SITE ADDRESS .....: 10231 MIRA VISTA AV SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OPERATOR: patg COPY # : 1 OWNER XI7.O HUANG ADDRESS .......... CITY/STATE/ZIP ...: CUPERTINO CA, 95014-2704 RECEIVED FROM ....: PLUMB IN TIME PLMB CONTRACTOR PAUL HENDRIXSON LIC # 27607 COMPANY PLUMB IN TIME INC ADDRESS 36C� MEMORIAL DR CITY/STATE/ZIP ...: CIF:YSTAL LAKE, IL 60014 TELEPHONE (8(6)293-3031 FEE ID UNIT QUANTITY INOUNT 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 ----------------- CHECK TOTAL RECEIPT AMOUNT --------------- 84.02 --------------- 84.02 VOICE ID DESCRIPTION -------- ---------------------------- 502 FINAL PLUMBING ENERGY 507 FINAL PLUMBING REFERENCE NUMBER -------------------- #52250 VOICE ID DESCRIPTION -------- ---------------------------- 506 GAS TEST *OF CUPEI�TINO CITY OF 1..UPERTINO WATER HEATER PERMIT APPLICATION FORM APN #3 5 "7 0� 03,21 0 0 Date: BUILDING PPERMITFEE Building Address: PLUMBING BENERGY Eiergy Owner's Name: Phone #: •au )A uA\nb L101• 1 -bo Contractor: Phone: License #: ?Lum b- 1 n -q" mr- g66"a5 - 5 bti VgS193 Contact: Phone: Cupertino Business License #: ` 71607 Building Permit Info: Bldg ❑ Elect LD/ Plamb Mech lJ Job Description: �e c� :ke Residential Commercial ❑ Cost of Project: Strapped Er On Platform ff Bonded New Location ❑ Replacement Qty. if Applicable Fee ID Fee Descriution Fee Grout) BPWHEATER . Water Heater / Vent BUILDING PPERMITFEE Plumbing Permit Issuance PLUMBING BENERGY Eiergy BUILDING BUSLIC Business License BUILDING sa_ CITY OF rUPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Buildi.n De artment JOB ADDRESS: Z e-/ / 1// % D/ fir PERMIT # ,? 6 �Go OWNER'S NAME: PHONE # Q a GENERAL CONTRACTOR: FAX # I am not using any subcontractors: S .gnature Date Please check applicable subcontractors SUBCONTRACTOR and coir fete u1e IV.UUwuL11LLV111LLAL-VLL. BUSI]vESS 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