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08120063
CTTY OF CUPERTINO •ga aw,. r .s.sx�--.,>;F BUILDING DIVISION PERNIIT CE�;Tr; �TpQA4JNA-•j�4TO , BUILDING ADDRESS: 4 PERMIT NO. 7569 BOLLINGER RD HOME DEPOT OWNER'S NAME: PERMIT'ISSUE DATE TINE: tA4*AA79e CONTROL NO. (425) 636-7054 ARCHrfECUENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 a0o LICENSED CONTRACTOR'S DECLARATION Job Description jV F 1 hereby&(limn,tit 1 am licensed under provisions of Chapter 9(commencing `M with Section 7MKf)ofl)i,tsion Sof NC Busincerand Prosssimu Code.and my license it +MM infu0ro=andeffecs REPLACE GAS WATER HEATER , j 'na Wcense Clus Lk.N =p Dam.Contractor ee 7W ARCHITECTS DECLARATION I undrsunta cnd my pla 'hell W u rec used public ords u 0' Lkevcd Pmrc4sional a OWNER-BUILDER DECLARATION z0 F I mjcu aRnn that 1 1. exempt Imus the Co License Law for site p O following mesion(Section 7031.5.L5,Business and wProfessions. Code:My city or county dm" which its iaau a permit re uirtoncl alter,improve,demolish.,fi c a sig any ommure 'iy pnormits issuable.odes requimshW applicant for such permitmfile&signed comment x < that W is licensed pennant W ftProvisions of she Cmnmcmrs Liceme LAW(Chapter 9 Sq.FL Floor Area Valuation y5s that W its(commencingexamish Section70M)the Division S ditWegedcuand Prd.My vi Code)Or 449 Q 5� that he u eumpl therefrom and Um bus for the alleged exemption My Holahan of Section 7031.5 by any spitiment for a pemrit subjeeet she applicant to a civil penalty of APN Number Occupancy Type not more dun five hundred dollars(SSW). 35922040. 00 Lo the werof thePr surdesormy wployces wiNwagnudin(hale campewness witsdrole".k,,nde,The CiamanmwLmede La.doactifessed for mul ppA,7a.,Baarca, Required Inspections w property Iso code:The CnnBannrs Lir."h.law dm rot apply 1f rt owner ar 9 P property wW Wllos or imProw dh impo and who am not work himulredtiuough his Own employes,provided posuchimprosememstaenot lean dedoff oraQtmd fdkstdcthe Owner. builder builder..Ne buildingtheor ed of pmmt b hath within one year of completion,theepose of builder wiB love tW WNen of proving that he did not Wdlo or improve for purpose of sok.). 1,as owner of the pmpeny,em exclusively convecting with licensed co mason an concoct dm pmjen(Sec.70",Busimss and Pmfessioro Cade:)The Convector's Li. comm Law does not apply as an owner of property who builds or improves shemon.and, who comm mut for such projects with a conuanor(s)licensed pursuant to the Conv actors Licxnx Law. C]1 am exempt undo sec. .B 8 P C(w Ni,mason Owner Date WORKERS COMPENSATION DECLARATION 1 hereby air=under pecalty of pmjay arc of the following declarWor,c I have and will maintain•Cenifia¢of Consent m self-insure for Workers Comprn- cal,as provided for by Section 37W of the labor Code.for the puff...of the work for which Nis permit is mracd. ❑1 have and will maintain Workers Compensation Irtaurance,as required by Section 37W of me LaborCode,for the peRormsnce of she work fenwhich this pemhi,is issued. My Worker's Compematiou Insdrsnce tuner and Policy numbs are: Cartier, Policy No.: CERTIFICATE OF EXEM MON FROM WORKERS COMPENSATION INSURANCE (Ihlssemion need not W completed ifthe permit is fondue hundred dollen(SIM) or less) 1 certify Net in the performance of the work for which this permit is issued,l shall not employ any pence.in any mmnerse as to become subject m me Wmiteri Compensaion Laws of Califomia.Date Applicant NOTICE TO APPLICANT:IL afar rnokmg this Certificate of Exemption,you should become subject to the WorteM1 Compensation provisions of the Labor Code you mum .J Z roMwish comply wish such provisions or the permit shall W deemed revoked. O CONSTRUCTION LENDING AGENCY I Wreby Num that then leacorowctim lending agency for the performance u( C> me work For which this permit k issued(Sec.3097.Cit.C.) Gicemen Name z Lenders Addrm U C) i cmify shot,i have mad cos applicatimand sum,til we above informed.U cotRLe I aims as comply with all city and County on it acts and 3=law,relating m .p Wilding construction,aM hereby anNusion repossmmhes of this city m enter upon me r ahove-mentioned property for impecdon purpo¢s gy, (Wer)agree to save,indemnify and keep bund.the City of Cupenim against rFA liabilities,Judgments.costs and exprnsu which may in any way attmnc against said City U Z in Consequence of the Zooming of thus permit ^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. Re-roofs Sil matuse of ApplicmUCo um"Luo Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applimem or future Wilding eccuPant slam or handle hmmdous material Is defined by dm Cupertino Municipal Code,Chapter 9.13,and the Health and Safety Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes ❑No will the applicant or future Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove Ll husemus sir cmumirwm u defined by the Bay Ana Air Quality Management all new materials for inspection. strict? ❑Yee ❑Na I hese mad du husNmuma rriaUrequiremcns mWcn&pkc G95 of hW Cadrm- ' nu Hal"Sifcty Cade,Savors25505.25533 and 25534.I undcmm,d rtatifthe Wilding Oscar on,eurtead,have a mime dual i,k my responsibility us nedfy we neeupan,nr the uspihemrlawhich mnrWOWL Prior missuance of.Cenwtmedraropaoy. Signature of Applicant Date Owner orsuNomcdagcnt Date All roof coverings to be Class'W'or better CITY OF CUPERTINO e 4 ITEMS OF 28 PERMIT RECEIPT OPERATOR: pdtg COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35922040 . 00 DATE ISSUED. . . . . . . : 12/04/2008 RECEIPT #. . . . . . . . . : BS000006760 REFERENCE ID # . . . : 08120063 SITE ADDRESS . . . . . : 7569 BOLLINGER RD SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : MEHTA, BHAVESH ADDRESS . . . . . . . . . . : 7569 BOLLINGER RD CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4334 RECEIVED FROM . . . . : JEFF JORDAN CONTRACTOR . . . . . . . : FRANK BLAKE LIC # 30610 COMPANY . . . . . . . . . . : HOME DEPOT ADDRESS . . . . . . . . . . : 12601 132ND AVE NE CITY/STATE/ZIP . . . : KIRKLAND, WA 98034 TELEPHONE . . . . . . . . : (425) 636-7054 • FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BSEISMICR VALUATION 449 . 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 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------- --------------- -------------------- CREDIT CARD 745 . 92 VISA --------------- TOTAL RECEIPT 745 . 92 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 518 WATER HEATER I • Community Development 10300 Torre Avenue Cup3228 .; ' Telephone tine A 9501 C OF Fax *CUPEI�TINO Building Department JOB ADDRESS: 7569 BOLLINGER ROAD PERMIT# O oo/ 3 OWNER'S NAME: MEHTA,BHAVESH PHONE# (408)255-5544 U/ GENERAL CONTRACTOR:HOME DEPOT �7 'FAX# 425-814-9516 I am not using any subcontractors:_ �'`' / '�` � 11/4/08 Signature Date Please check applicable subcontractors and complete the following information: 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 SOwner/Contractor Signature Date 8�a�3 000000 Permit No: (office use only) City Of Cupertino Building Permit Application E-Mail: Building-Permits(,a'kupertino.om (Address is case sensitive). Jobsite Address:7569 BOLLINGER ROAD Date: 11/4/08 Assessors Parcel Number. 35gJ 0 � Owners Name: MEHTA,BHAVESH Phone No: (408)255-5544 Project Valuation: 449.00 Building Permit Info: Bldg Elect Plumb X Mech Job Description Remove/Replace Gas Water Heater Contractor Information Company Name: HOME DEPOT Phone No: Contact Name: Carol Randall Fax No: 800-454-8955 Address: 12601 132ND AVE NE E-mail: carolr@fastwaterheater.com City, State & zip code: KIRKLAND, WA 98034 State Contractor's Lic. No: 602331 Expiration Date: 9/30/lo Workers Comp No: 1928756 Expiration Date: 3/1/09 Carrier. AMERICAN HOME ASSURA City of Cupertino Business License No: 1Q(xl�zd Credit Card Information Credit Card No: Expiration Date: 11/10 Name on Card: Jeff Jordan Visa © MasterCard ❑ American Express ❑ • The Building permit application and a completed & signed contractor/subcontractor form need to be submitted with each permit.