08120123BUILDING DIVISION PERMIT
NAME:
uO LICENSED CONTRACTOR'S DECLARATION
m 1 hereby affirm Net I am licensed under pmsivons of Chapter 9 (comic=ing
Z� with S=tion 7IXXI)of Diviaioa 3 of the Business and Professions Code. eM my liecom is
_ � N in full forte and e(fea 627364
j �? License 1 Lk. N
b, p Dalc Contruwr sq r
7W ARCHRECI-S DECLARATION
< I understand my plain shall be used As public mcnrds
D -u
4OH Licensed Professional
3 OWNER -BUILDER DECLARATION
'.g I hereby aff m that I am exempt from the Contractor's License Law for the
D o following moron. (Suction001.
75, Business and Profns essioCade: Any city or county
COO
$ which requires a permit to c=vucL altar. Improve, demolish. nr repair my shonum
y =Attar to its issuance, also requires the applicant for such permit us Glc aligned woman,
< that he u licensed pursuant b Nprovisions Of provisioof the Canlrmtor's LJccom Law (Chapter 9
AtS
y-G (commencing with Section70DG) of Division 3 of due, Business and Professions Code)or
y e5 9
that be is exempt therefrom and the buffs for the Alleged exemption. Any violation of
Section 70313 by any applicant for a permit subjects Jin applicant m a civil Penalty of
Out mom Nm five hundred dollars (S500).
❑ I, u awrcr of Ne property. m my wployma with wages u Ne'v ante compensaJon,
wili do the work and e: sanctum ra rot Ntanded re caw do fm apply
7016,chaw of
and Professions Code: The Camocbls Liana Law dao Out apply ff an owner is
Property who Wiprovidd tat
Wpm
and who does suchwmkhimuamilWr agn his
awn employees, prodded Nal ve, imProwmmts are not ea: of completion.
mpeesW rue saie. r..
ludwever. have
use, or impmvemving saidwithinemyearofcompletion,Neowmr-
builder win haw tW WNm of proving Nat be did not build m improve for Puryo¢ of
ole.).
❑ 1, As owner of the property. Am exclusively contracting wish licensed mnwcmm N
construct the project (Sec. 7014. Business and Professions Code:) The C=u cem's LI-
cesse law dma not apply to an owner of property who builds or improves demon, and
who contracts for such projects with acanmctor(a) licensed pursuant to not CDnvacmr's
License Law.
❑ I ore eaempt under See. . B & P C for this nessme
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under peaty of perjury am of de fallowing declarations:
❑ I have and will maintain a Certificate of Consent (a self-Insum for Worker's Compen-
.due, as provided for by Samion 3710 of the labor Cade, far to performance of the
work for which Nu permit is Lssmd.
1 haw and will maintain Wark es Compensation I... As Ace tired by Sado.
of the Labor Code, for the parformmcc of Ne work for which Nu permit u issued.
Worker's Compensation Insararne carrier and Poli, wnu-,m.�ber am: .a
carrier. 'J rr tv A-- Poli, No.:40f0 A /8 >63
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
cres section Aced rot W complete) if the permit Is free= hundred mgm, ($100)
car leve)
1 artily, Nat in the Wfarmanec of Ne work far which this commit is issued. l Mail nm
employ any person in any mamrer m as; m become subject to the WorkeR Compensation
Laws of Caffun ice. Dau
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to Na Worker] Compensation provisions of the Labor Cade. you most
., z fnrlhwith comply with suchprowd.. At Nis permit shall be deemed revoked.
'Z '-" CONSTRUCTION LENDING AGENCY
E4 I hereby affirm Net Nem is. construction, er
laming.,nr the perfomm=
ac of
> the work for which this permit is issued (Sec. 3097, Civ, C.)
Le
Wnder's Name
� Q
a) z LmateaAddress
U O I certify that I have mad this application and sine Nu Ne above information is
L H comem I egme to comply with all city and county ordinances and stale laws mlaong to
DU building convection, and hereby authorise mpmsematives of his city N enter upon d¢
i' U above-mentiomd property for impaction purposes
(We) agree to saw, indemnify and keep harmless the City of Cupertino against
rh liabilities, judgments, costs and apcnsa which may in my way accrue against Mid City
U in conseq=me of the grmting of this foment.
ti APPLICANT UNDERSTAND N LL COMPLY WITH ALL NON -POINT
SOURCEREGUEWM
HAZARDOUS MATERIALS DISCLOSURE
Will tho applicant., future Wilding occupamstom or bandle hmend us material
As defined by ft Cupertino Municipv . Chapter 9.12 and Jc Health and Safety
Coda Section 25532(.)7
❑Yes No
Will the applicant or ru=m Wilding occupant use equipment or devices which
emit harafdous air eondminams u med by the Bay AMA Air Quality Management
District?
❑Yo No
aChaardmm6 quimcments under ChapW6.95ofNeCabrar-
s nith c&foaaSedna2505.25533md2SM.lundmdNuifin Wilding1�Hcao1thwmJy New a tanLditumy msponsihility m notify Jw uccupmt of On.
2 //5/of
REMV RPLC WTR
Area
Issued by:
Re -roofs
Type of Roof
Job Description
Required Inspections
ISSUE DATE
Date /2—/Gad—'
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class '%}" or better
CITY OF CUPERTINO
4 ITEMS OF 12 PERMIT RECEIPT
• Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 35928040.00
DATE ISSUED.......: 12/19/2008
RECEIPT #.........: BS000006863
REFERENCE ID # ...: 08120123
SITE ADDRESS .....: 1048 COLONY HILLS LN
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: patg
COPY # : 1
OWNER .............. WIEGLER NORBERT AND HELENA
ADDRESS ..........: 1048 COLONY HILLS LN
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-5802
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT :
AMOUNT
---------------
319.68
---------------
319.68
VOICE ID DESCRIPTION
---------------- -----
518 WATER HEATER
REFERENCE NUMBER
--------------------
MC
VOICE ID DESCRIPTION
RECEIVED FROM ....:
EDDIE D NALLEY
CONTRACTOR .......:
LEONCE ROUX LIC
# 26850
COMPANY ..........:
AFFORDABLE WATER HEATERS
&
ADDRESS ..........:
24707 RAILROAD AVE
CITY/STATE/ZIP ...:
SANTA CLARITA, CA
91321
TELEPHONE ........:
(661)259-7131
FEE ID
UNIT QUANTITY
AMOUNT PD -TO
-DT THIS REC
NEW BAL
•1BSEISMICR
--
VALUATION 1,500.00
---------- -
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
---------------
319.68
---------------
319.68
VOICE ID DESCRIPTION
---------------- -----
518 WATER HEATER
REFERENCE NUMBER
--------------------
MC
VOICE ID DESCRIPTION
CITY OF
CUPERTINO
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
10 q g 0-3), W
PERMIT #
0 LF( , -L 01 -L-
OWNER'S NAME: ( r gVrd 1„/ ; e5 Ir ✓
PHONE # N 0�- 72f - P2 Yl
GENERAL CONTRACTOR: Y) "o
FAX #
I am not using any subcontractors: �1
Re Date
Please check applicable subcontractors and complete the following information:
40 Owner/ Contractor Signature Date
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
40 Owner/ Contractor Signature Date
oil zwz3
CITY OF CUPERTINO
Vf` WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
D
APN #D
21-) J' J J
ate:
5q2-
z11S e�
Building Address:
�,1(S
C1./
/O -1 g, col oliy
Owner's Name:
yo%'ar tn�i�Sl�f
Phone #:
`js�- 7Z�-1z8�
Contractor:
Phone #:.(�� I ZS y-71 3/
Fax #:
Cupertino Business License #:
Contractor State License #:
to Z73t.J'
Contact: .
Phone #: (6/ 455 ,. 7/3/
Fax #: - ZS Sly
Building Permit Info:
Bld ❑ Elect ER!
Plumb Mech El—
Residential
Commercial ❑
Job Description:
2���Q�Q 50
Strapped On Platfo Bonde New Location ❑ Replacement
Valuation (cost of project): J s6 U
Project Size: Express ❑ Standar
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:
40 Revised 6/16/08
ITM OF
CUPERTINO
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
1TRAVDOC
Travel &
Documentation
B
1BUSLIC
Business License
B
0
0