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08120025CITY OF CUPERTINO5 NI''QRMATI©N BUILDING DIVISION PERAHT #CONTRACTOR BUILDING ADDRESS: PERMTTNO. , 1124 D OWNER'S NAME: PERMTr ISSUE DATE '2008 SA CONTROL N0. ARCHiTECT/ENGINEER: BUILDING PERMrr INFO BLDG ELECT PWMMECH WATER HEATER REPLCMENT l� LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm Wt I w licensed under provisions of Chapter 9 (Commencing wflh Sccdon 7000 of Division 3 of the Business and Profnssiom Code. and my license is in full tufa and ctrec. , L(c.. Clw Lic.0 . Date Contractor. ARCHITECTS DECLARATION 1 understand my plus shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am attempt from tk Contractors License Law for tk following reason. (Section 70316, Busircss and Professions Cede: My city or County which Octal. a Permit to consensus. cher, Improv. demolish, , repair any structure prior to its issuance, also requires be applicant (or such Permit to file a signed statement Contractor's Litemse Law(Chapter 9 Sq. Ft. Floor Area Valuation that he is liccvcd pursuant to the previsions of tk (commencing with Steven 7000) of Division 3 of the Busintu and Profusions Code) or 1 that be is tanmp tbcmfmm tab tit basis f, the alleged Consumption. Any violation of APN Number Occupancy Type Section 7071.5 by any applicant f, a permit mbjccu de IPplicanuo arnil pevlty of not mom Nut five hundred dollars, (SM Q I. v owns of tk prvpmy. o mY employees atilt cages ss tktr role cempewdm, Required Inspections will de mowers, and Ne structure h winmrWed or effttecl fosam (see 7M4. Becomes and Professions Code: The Conmms's License Law dons Out apply N an owner of pmpnywMbuiidsoimpeseademmn.mdwMd ssmhwmkhimaelferdbmghhu own cmploym,pmNded that such improwmanssam notintendedooRmnd n. de ✓e Cold within ane year of completion, tk awrcOf however. the Wilting Orden Of pmanl builder wail Nw de WrMa e[ pouring that k did mol build ter improve for puryese of ule.k 14� C. as mance of Ne pmp ,, am tscle iwly sentMing with licensed comae on m Co tinct the Project (Sec. 7(H4, Business and Profudens Codc)'Dne Contractors U- cease law docs not apply N an oamer of property who builds or improves thereon, and. wkcontncu for such Prolecas with aConuan,(s) licensed pmsuam m the Centraanfs Lleeve Law. tppt u� C for is n � r �.L/� WORKER'S COM T"C II hereby aPrtm under ptWly of perjury oro of the following declarations: haw and will maintain acm,iftote ofcoment as ulf-insum for Workers Compry Don, an provided for by Section 37M of the labor Code, f, the Performance of Ne wrote for which this pcmtit is issued. ❑ 1 have and will maintain Wmae's Compensation Ivwvta. a required by Section 17W of the Ialmr Code, f, dtt perfwmmce of the work for which this Permit is issued ' My Workers Compensation Wuuna Cartier and Palley number art: Gsicr. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE ('Thu term d Out M completed i(de pman mol is for hundred dollan($100) tor less) 1 anify Nat in tic performance of the work for which this permit u issued. I shall not employ any Perron in any manycSm sspbecmnemhteclm Ne Worecreacmpnsa0m , Laws of CalifomyJ"�� paam L!i T .!M X Applicant (r//.1; t NOTICE TO APPLICANT: If, after ma dog this Certificate of Exemption, you should Weems, subject N tk Worker's Compensation provisions of Ne lab, Code you most v forthwith comply with such povidons or this permit shall be dcemnd rewknd. CONSTRUCTION l.FllDINO AGENCY faarnm mf 1 kre.Bim that them is. Conmmtinn lensing agency nor the perrtn the wart which i<h Nis pmol is issued (Ss,. 3097. Civ. C) ' Leader's Name wrderandareaa 1 certify Nat I have read this application and etas than tk ahave information is correct. l agree N comply with all city and county eNinamss and state Ise miming In building consuune ion, and bereby a ndsm. reprexeudves of this city m cnmr Open the above-men0mmd property f, inspection puryuas (We) agree to caw, indemnify and keep hammlw the City of Cupertino against r4j Ilabilitiu,judgmc.U. costs and ettpemva which may in any way... against said City in Consegsence of Ne Zoneng of Nis permit. APPLICANT UNDERSTANDS AND WILL COMPLY WMf ALL NOWPOINT Issued by: Date SOUR IIUL NS. Re -roofs �L/i /1�DT�cP Signature of AFplianVConwclor Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will tit appllcam., future Wilding mcupant mom o handle hvudous material at de0md by Use Cupertino Municipal Cade. Chapter 9.11. and the Health and Safety Cane, section 25531(.)± All roofs shall be inspected prior to any roofing material being installed. ❑Yes VNO If a roof is installed without first obtaining an inspection, I agree to remove Will Ne.pPliant or fu Wilding occupant um Nuipmenl or devices which t 1.1dr: air mnuminants as derinuM by the Bay Area Air Quality Management co 1c all new materials for inspection. on"? [:1 Yet XNe alifor- I how read the hanN wee materials mquimmcnu under CNP¢r G95 of tM Califor- nia Hal" SgctyCo&, niaHml"SafctyCede, Section 15505.2551] am125334. 1 understand that if the Wilding deco not currently haw a unant. now it is my responsibility to notify the occupant or the nm miltj n nm bemet rN eatRaenCmre.mer Ow-Mdl SignatureofApplicant Date �� `7 / ' ' /D� All roof coverings to be Class'/¢" or better Dau Owner or anNerisd agent • 4 ITEMS OF 4 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 36221034.00 DATE ISSUED.......: 12/03/2008 RECEIPT #.........: BS000006736 REFERENCE ID # ...: 08120025 SITE ADDRESS .....: 1124 DERBYSHIRE DR SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OPERATOR: patg COPY # : 1 OWNER ............: DARLEE LEE ADDRESS ..........: 1124 DERBYSHIRE DR CITY/STATE/ZIP ...: CUPERTINO CA, 95014-5072 RECEIVED FROM ....: CHESTER YEH CONTRACTOR .......: LIC # *OWNER* COMPANY ..........: DARLEE LEE ADDRESS ..........: 1124 DERBYSHIRE DR CITY/STATE/ZIP ...: CUPERTINO CA, 95014-5072 TELEPHONE ........: SFEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL 1BSEISMICR VALUATION 0.00 0.50 0.00 0.50 0.00 IPPERMITFE 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 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 106.56 --------------- 106.56 VOICE ID DESCRIPTION ------------ ----------- 518 WATER HEATER • REFERENCE NUMBER -------------------- AMEX VOICE ID DESCRIPTION CITY OF •CUPEkTINO 4 CITY OF CUPERTINO WATER HEATER PERMIT APPLICATION FORM oylaoC),DT APN # ., ..Qua/03L/ �o Date: Building Address: IIA ` gpwSgttE Q5a14 Owner's Name: UF,Tm `N Phone M 40&-715-�Q14 Contractor:nn,,'' UE)Tm y" Phone #: . Fax #: Cupertino Business License #: Contractor State License #: Contact:Ut-%M Y� Phone #: Fax M Building Permit Info: Bld ❑ Elect ❑ Plumb Mech ❑ Residential Commercial ❑ Job Description: WAM �mEa, kvtAtEmE&) Strapped M On Platform Bonded New Location ❑ Replacement Valuation (cost of project): $ Project Size: Express ❑ Standard Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Green Building Points achieved: Revised 6/16/08 xie T'OF CUPEkTINO CITY OF CUPERTINO WATER HEATER PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group Permit Type 1PCWHEATR Commercial Water HeaterNent B PCWHEATR 1BSEISMICOM Seismic Commercial B / 1PRWHEATR Residential Water HeaterNent B PRWHEATR 1BSEISMICRE Seismic Residential B 1PPERMITFEE Plumbing Permit P J 1TRAVDOC Travel & Documentation B 1BUSLIC Business License B .I, 0 0