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07090086!CC :mP :UL ,ao t2? i�- rat .o, jy. 30< =E =r =i z Lia Lir r7 U V. 0 H U CITY 4F CUPERTINO PERMIT GI7R��C1] IFMATI,1Y' BUILDING DIVISION PERMIT NO. BUILDING ADDRESS: 1124 DERBYSHIRE DR PLUMB IV TIME INC 07090086 PERMIT ISSUE DATE OWNER'S NAME: , DARLEE LEE 360 MEMDRIAL DR 09/14/2007 SANITARY NO. CONTROL NO. NE: (866)29 )-3031 BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is REPLACE WATER HEATER; 50 GAL GAS. in full force and c License CI s Lam• # Dare Contraclmr ARCHITECT'S DECLAR VON 1 understand my plans shall he used as public records i iLicensed Professional OWNER -BUILDER DECLARATION i 1 hereby affirm that I 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 9 Ft. Floor Area Valuation Sq • t that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter Code) 700 (commencing with Section 7000) of Division 3 of the Business and Professions or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of *��Tt Number Occupancy Type not more than five hundred dollars ($500). 36221034 U ❑ 1, 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 Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through 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.). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li- ccase 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. ❑ 1 am exempt under Sec . B & P C for this reason Owner Date WORKER'S COMPENSATION 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 Worker's Compen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 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 Worker's Cpmpe lion I nce carrier and Policy number are: Cartier. ��) 7Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed i[ the permit is for ane hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY V) I hereby affirm that there is a construction lending agency for the performance of > the work for which this permit is issued (Sec. 3097, Civ. C.) L.endces Name z~ Lender's Address I certify that I have read this application and state that the above information is r correct. I agree to comply with all city and county ordinances and state laws relating to Ubuilding construction, and hereby authorize representatives of this city to enter upon the Lta above-mentioned property for insp9600Ipurposes. /17 (We) agree to save, inderM1ntfy ytd,keep harmless the City of Cupertino against liabilities, judgments, costs d exprtt$eswhich may in any way accrue against said City in consequence of the n o is ' rmit. g Date 2 6 iisw APPLIw UNDER A $ .0 O WILL WIT LL NYN;P�NT Issued b) : SOU REGULATI N -Re-roofs/ . sidqtc of Appliiiant/C tractorr HAZARDOUS MATERIALS TSC SUR Type of LOOP Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety Code, Section 25532(x)? �� All roofs shall be inspected prior to any roofing material being installed. , ❑ Yes SCJ no If a roof is installed without first obtaining an inspection,agree to remove .I Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants ncd by the Bay Arca Air Quality Management all new r iaterials for inspection. District? C] Yes o I have read the c>4aterials requirements under Chapter 6.95 of the CaliCor- niaHealth &Safety 2550 25533 d255341undcrstandthatiCt(rebuilding docs not currenU ant. tha ' ism pmnsibili notify the ott t n require ms met rwi ancce rreateeroe�l. SignaturcofApplicant Date All roof coverings to be Class "B" or better Ow r auth riztd agent are CITY OI' CUPERTINO 3 ITEMS OF 9 PERMIT RECEIPT Sec: Twp: Rng: Sub: B].k: Lot: APN ........: 36221034.00 DATE ISSUED.......: 05,/14/2007 RECEIPT #.......... BS000002639 REFERENCE ID # ...: 0"090086 SITE ADDRESS .....: 13.24 DERBYSHIRE DR SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ...... OPERATOR: patg COPY # : 1 OWNER ............. DI,RLEE LEE ADDRESS ..........: 13.24 DERBYSHIRE DR CITY/STATE/ZIP ...: CUPERTINO CA, 95014-5072 RECEIVED FROM ....: PLUMB IN TIME CONTRACTOR .......: PlUL HENDRIXSON LIC # 27607 COMPANY ..........: PLUMB IN TIME INC ADDRESS ..........: 360 MEMORIAL DR CITY/STATE/ZIP ...: CIRYSTAL LAKE, IL 60014 TELEPHONE ........: (E�66)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 40.79 0.00 40.79 0.00 TOTAL PERMIT ---------- 86.44 ---------- 0.00 ---------- 86.44 ---------- 0.00 VOICE ID DESCRIPTION -------- ---------------------------- 502 FINAL PLUMBING ENERGY 507 FINAL PLUMBING VOICE ID DESCRIPTION -------- ---------------------------- 506 GAS TEST *QF' CUPEkTINO CITY OF CUPERTINO WATER HEATER PERMIT APPLICATION FORM 070'c)00( -o APN # Water Heater / Vent BUILDING Date: Plumbing Permit Issuance PLUMBING BENERGY Emergy Building Address: BUSLIC Business License BUILDING 1 )t-1 re Owner's Name: Phone #: �CICA,occ- Ue L-Ibs• -i)S- D�� Contractor: I Phone: License #: ?Lu" to -1 06 • a51 3t-31,. goy SbgS'111 Contact: Phone: Cupertino Business License #: 77607 Building Permit Info: Bldg ❑ Elect Plumb Mech C Job Description: 9�e Le -k �Q Residential g Commercial ❑ Cost of Project: Strapped On Platform El Bonded ❑ 15 New Location Replacement Qty. if Applicable Fee ID Fee Description Fee Group BPWHEATER Water Heater / Vent BUILDING PPERMITFEE Plumbing Permit Issuance PLUMBING BENERGY Emergy BUILDING BUSLIC Business License BUILDING CITY OF "TPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: l L r� -Y� ��' PERMIT # 0-70,:dD 42,6 OWNER'S NAME: a./ PHONE # GENERAL CONTRACTOR: v,/yc - , ,N' I 4Z- - FAX # I am not using any subcontractors: Signature Please check annlicable subcontractors and complete the following information: Date c� . r d C�ei/ Contractor Si a Date SUBCONTRACTOR BUSI14ESS 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 , c� . r d C�ei/ Contractor Si a Date