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10030171 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10138 COLD HARBOR AVE CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO: 10030171 DATE ISSUED:03/30/2010 OWNER'S NAME: CALVIN LEUNG PHONE NO: ER'S PHONE: 4088732271 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT F PLUMB F License Class Lie.# MECH F RESIDENTIAL f— COMMERCIAL Contractor Date JOB DESCRIPTION:REPLACE WATER HEATER I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$900 1 have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this anc Type: occupancy permit is issued. APN Number:36909043.00 P Y YP APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: Date: 9.18. Signature Date RE-ROOFS: CJ OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air contaminants as de Section 3700 of the Labor Code,for the performance of the work for which this fined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. 1 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 Worker's Owner or aufhorijzed gent: Compensation laws of California. If,after making this certificate of exemption,I Date: 30 become subject to the Worker's Compensation provisions of the Labor Code,I must s% forthwith comply with such provisions or this permit shall be deemed revoked. 10 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save mify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. � Licensed Professional Signature Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 36909043 . 00 DATE ISSUED. . . . . . . : 03/30/2010 RECEIPT #. . . . . . . . . BS000010059 REFERENCE ID # 10030171 SITE ADDRESS 10138 COLD HARBOR AVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER CALVIN LEUNG ADDRESS 10138 COLD HARBOR AVE CITY/STATE/ZIP CUPERTINO, CA 95014-3327 RECEIVED FROM EVA Y PANG CONTRACTOR TBD - TO BE DETERMINED LIC # 00096 COMPANY TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- -- 1BCBSC VALUATION 900 .00 1. 00 0 . 00 1 . 00 0. 0 1BSEISMICR VALUATION 900 .00 0 . 50 0 . 00 0 . 50 0 . 00 1PPERMITFE FLAT RATE 1 .00 42 . 00 0 . 00 42 . 00 0 . 00 1PRWHEATR UNITS 1 .00 25 . 00 0 . 00 25 . 00 0 . 00 1TRAVDOC FLAT RATE 1 .00 42 . 00 0 .00 42 . 00 - - 0_00 ---------- ---------- ---------- TOTAL PERMIT 110 . 50 0 .00 110 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- - CREDIT CARD 110 . 50 AMEX --------------- TOTAL RECEIPT 110 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- -------- ---------------------------- -------- -------------------- 518 WATER HEATER 17 1 CITY OF CUPERTINO WATER HEATER CUPERTINO PERMIT APPLICATION FORM APN # Date: c-� Building Address: 101 ,59 Cvld "tN:,har X19 , C:,. �''�v, CA , '1S`o1q, Owner's Name: Phone #: Kt r4 rA:V1 Le�� , �, V, Contractor: Phone #: 4 c 8 Fax #: Cupertino Business License #: Contractor State License #: Contact: Phone #: 3 �z Ev&- ea Fax #: Building Permit Info: Bldg []' Elect Plumb �� Mech Residential ❑ Commercial ❑ Job Description: I P1 �,303�� K Strapped 9--On Platform ❑ Bonded �ew Location ❑ Replacement Valuation (cost of project): � 6'1 " 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 03/10/10 CITY OF CUPERTINO WATER HEATER CUPEkTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Permit Type Group 1PCWI EATR Commercial Water B PCWHEATR HeaterNent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICOM Seismic Commercial B 1PCSWHTR Commercial Solar B PCSWHTR Thermal Water Htr 1 PRWHEATR Residential Water B PRWHEATR HeaterNent 1PRSWHTR Residential Solar B PRSWHTR Thermal Water Htr 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee / 1BSEISMICRE Seismic Residential B 1 PPERMITFEE Plumbing Permit P 1 TRAVDOC Travel & B Documentation 1BUSLIC Business License B Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C O P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: Cep �b� PERMIT# �� OWNER'S NAME: ,' .n PHONE# 1 GENERAL CONTRACT Q Yl BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY HAVE OBTAINED AHCITY OF CU ERTINO UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS BUSINESS LICENSE. I am not using any subcontractors: Date Signature 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 Painting /Wallpaper Paving Plastering Plumbing Roofing Septic Tank r et Metal et Rock e _112t77;�� Owner/Contractor Signature Date