09060033 MY OF CUPERTINO ..........
V
BUILDING DIVISION PERAUT
PERMIT NO.
BUILDING ADDRESS:
' R HPATER 09060031
PERMIT ISSUE DATE
OWNER'S NAME:
S A CONTROL NO.
800) 4`,4-8955
BUILDING PERMIT INFO
ARCHiTEC IENGINEER: ELECT PL! (�
p LICENSED CONTRACTOR'S DECLARATION Job Description
v p I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z
U with Section 7000)of Division 3 of thc Businessand Professions Code.and my license is REMV/RPLC GAS WTR HTR
a y in full fora and effort
Z License Class Lle•N
t Date Contractor
t ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
ul yU
Cy Licensed Professional
H 3 OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
p O following mason.(Section 7o315,Business and Professions Code:Any city or county
m Pi which requires a permit to construct,alter.improve,demolish.or repair any strocturo
0 prior to its issuance,slur requires the applicant for such permit to file a signed statement ,Ft.Floor Area Valuation
f < that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 •1Q
(commencing with Section 70D0)of Division 3 of the Business and Professions Code)ormption.Any violation of r)0
.. that he is exempt therefrom and
for
the�basis for t all aed�Iicant to a civil penalty of ApN Number Occupancy Type
Section 70315 by any applicantP subjects pp
not more than five hundred dollars(5500). 34233007 . 00
0 1,as owner of the property,or my employees with wages as their sok 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 hit
own employes,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.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Ctmtracmes Li-
cense law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractm(s)licensed pursuant to the Contractor's
License Law.
0 1 am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insum for Worker's Compen-
..rtion,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
0 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 Worker's Compensation Insurance carrier and Policy number am:
Cartier Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Chis section need not be completed if the permit is formic hundred dollars($100)
or less)
I certifv 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 m the Workers'Compensad a
Laws of Califoroia.Dam
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
0 forthwith comply with such provisions or this permit shall be deemed revoked.
N
"'' CONSTRUCTION LENDING AGENCY
�1-. I hereby affirm that then:is a construction lending agency for the performance of
>!i > the work for which this permit is issued(Sec.3097,Civ.C.)
QLender's Name
Z Lender'sAddrss
O 1 certify that I have read this application and state that the above information is
4 0" correct.1 agree to comply with all city and county ordinances and state laws relating to
5 U building construction,and hereby authorise representatives of this city to enter upon the
w W above-mentioned property for inspection purpose&
y a (We)agree to save,indemnify and keep harmless the City of Cupertino against
y to liabilities,judgments,costs and expenses which may in any way accrue against said City
Z in consequence of the granting of this permit. Date
1-4 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by.
SOURCE REGULATIONS.
Re-roofs
Signature of Applicant/Conlracmr Date
HAZARDOUS MATERIALS DISCLOSURE Type of]Roof
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(a)? All roofs shall be inspected prior to any roofing material being installed.
0Yes ONO
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
L hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
strict?
[3 Yes [I No
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&SafctyCode,Sections 255U5,25533 and 25534.1 understand thatif thc building
does not currently have a tenant.that it is my responsibility to notify the occupant of the
requirements which most be met prior to issuance of a Certificate of Occupancy. Signature of Applicant Date
All roof coverings to be Class'A"or better
Owner or authorized agent Date
�iJ� 445886 A
C
Permit No: t�J
(office use only)
i
City Of Cupertino Build,ing Permit Application
E-Mail: Building-Permits@cupertirio.or (Address is case sensitive).
Jobsite Address:22822 LONGDOWN RD Date: 5/29/09
Assessor's Parcel Number: 3g2.5 3oo7L Ca
Owners Name: MILAM, BILL Phone No: (408)253-0733
Project Valuation: Ign 60
Building Permit Info: Bidg Elect Plumb X Mech
Job Description
Remove/Replace Gas Water Heater
Contractor Information
Company Name: FAST WATER HEATER COMPANY Phone No:
Contact Name: Julie Caskey Fax No: 425-636-7084
Address: 12601 132ND AVE NE E-mail: carolr@fastwaterheater.com
City, State &zip code: KIRKLAND, WA 98034
State Contractor's Lic. No: 877489 Expiration Date: 5/31/10
Worker's Comp No: A09304455 Expiration Date: 12/1/09
Carrier: Truck Insurance Exchange
City of Cupertino Business License No: 29100
Credit Card Information
Credit Card No: 4417123041349530 Expiration Date: 11/10
Name on Card: Jeff Jordan
Visa ❑X MasterCard ❑ American Express ❑
The Building permit application and a completed & signed
contractorlsubcontractor form need to be submitted with each permit.
P17- Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
a or Fax(408)777-3333
CUPEkTINO
Building Department
JOB ADDRESS: 22822 LONGDOWN RD PERMI j-# O
OWNER'S NAME: MILAM, BILL PHONE/# (408)253-0733
GENERAL CONTRACTOR:FAST WATER HEATER COMPAN FAX# 425-636-7085
I am not using any subcontractors:._ 6A _ 5/29/09
Sigr attire Date
Please check applicable subcontractors and com l,Ae the following information:
SUBCONTRACTOR BUSINI?SS 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