07110121 CITY OF CUPERTINO �.� '
BUILDIPIf;±tIY�:�:f�y PERMIT 1 �������� ��������:
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_ PFRMIT NO.
BUILDINGADDRESS: FAST WA'PER HEATER 07110121 .
22398 MCCLELLAN RD
pERM1T LS6UE DATE
.��VNER'S NAME: ' 1 1� 2 1� 2 O O 7
ADAM WIJ 12601 132 AVE NE
SANiTARY NO. CONTROL NO.
PHONE: �gOO� 454-8955
BUiLDING PERMR'1NF0
ARCHITECC/ENGINEER: BLDG ELECT PLUMB MECH
� � � 0
� p 0 LICENSED CON7'RAC!'OR Dec�.nRaT�oN Job Description
� I hcrcby aflirm Ihat I am lixnscd undcr provisiona of Chaptcr 9(cammcncing
� z� wi�h Sccdon �000) of Division 3 of the Business and Pro(cssions Codc, and my Iicensc is REMOV E/ RE P LC E GA S WAT E R H EAT ER
�� r d„ in fuU forcc and efta
� v� z Licenae pasa � Convaewr
y � o Da�e � — FY
� ARCHiTEC1'S DECLARATIO
��< l undcrstand my plans shall 6c wcd as public rccards
�yU
4 O y Licenscd Pru[cuianal
y � OWNER-BUILDER DECLARATION
�' 1 hcreby affrm �at 1 am excmpt Gum �hc Convactor's Liccnsc Law for thc
'� p O following sasan. (Sxuon 703 L5, Busincss and Profcssioos Cafc: Any ciry or counry
K$ E� which rcquims a permit w consuucG alter, im{xovc. dcmal'GCh, or �epair any suucwrc
y' y prior w i�s issuancc, alw rcquims thc applicant for such permit to filc a signcd s�a�cmcnt S Ft. Floor Area Valuation
Z< �at he is lieenscd pursuanl to thc provisions o[ thc Convxtor's Liccnsc Law (Chaptcr 9 9• $ 4 4 9
x I s -� �(commencing wiU� Sccdon 7000) of Division 3 of ihc Busincss and Profcssions Cadc) ur
y�� that he ia exempt thacfrom and the basis (ur the alleged eumpdon. Any violatian of Number Occupancy Type
Sectlon 7031.3 by siry applicant for a pe�mit sabjecu ihe applicant w a civil penalty of 3 5 6 0 4 0 �� 5: t7 �
not more than five hundred dollars (5500)•
❑ I. u ownec o[ ttie property. or my employees with wages u the'v sole compensadon,
will do U�e work, and the stcucw�e is not intended or oftered for sa� (Sec. 7044. Husinw Required Inspections
md Pro[essions Co�: The Conuuwrs License Law does not apply to an ownu of
pcopeny wha builds or improves tt�ereon, and who does such work himul[or through his
ow� p�pluyces, provided that such improvemenu ue no[ inanded or olkrcd (or sate. If,
however. U�e building or improvemuu ia sold within oro year of completion, the owner-
builder will have �he burden o[ pcoving that he did not build or improvc tor purpose of
sak.).
❑ t. u awner o[ the property. sm wcelusively conuacting with ticenaed rnnvactors w
consuuct the projett (Sec. 7044. Business and Professions Cade:) The Convacmra W-
ccnse Law dces not apply W an owner of property w�w bai�ds or improves Urcceon, �nd ,
who conuacts far such projects with a eontrutor(s) licensed pursuant to ihe Contrsctor's
' '^.ense Law.
I am exempt undu Sec. , B& P C for this rcawn
Owner Date
WORKER'S COMPENSA770N DECLARATION
1 hercby �tm under penalty o[ perjury onc o[ �he following declarations:
❑ I hsve and will mainuin a Certificate of Consent to xlf-insure for Worker's Compen-
astion, as providcd for by Secuan 3700 af the Labor Code. for the performaircc o( thc
work for which ihis pertnit is issued.
❑ I havc and will mainuin Workcr's Compensaaon Insurance, u �equired 6y Scction ,
3700 of the Labor Codc, Cor thc performance o( the work for which this pertni� is issued
My Worker's CompensaC n Insurance cam and Poliry number aie:
�� . Poliry No.: J ���Z.—
C RTIFICA OP E�ON FROM WORKERS' .
COMPENSATION INSURANCE
(This scction �cd nat bc completed it lhe permit is for onc hundred dollats (5100) .
or Icss.)
I cenify Ihut in ihc performance of �hc work for which �his permit is issucd. 1 shall not
cmploy any person in any manncr so u w bcrnmc subjcct w the Workccs' Compcnsauon
Laws oC Catifomia Da�e
Applicant
NOTICE TO APPC.ICAM: If, aMr making �his Cenitiwtc of Excmption, yau shoulJ
bccome subjcct to thc Worker's Compensation provisions of iAc Lsbor Codc, you muu
� z forthwiW comply with such pmvisions or this permi� shall bc dccmcd revokcd.
Z � CONSTRUGTION LENDING AGENCY
E..� �.�,., 1 hemby aflirm �hat thcre is a consUUCtinn Icnding agcncy Cor ihc perCortnancc uf
a„ � �hc work for which �his permit is issued (Sec. 3097. Civ. C.) .
W Q Lendcr's Namc
? z L.cnder's Addicss
V � 1 cenifY ihat I have rcad this applicaBon and sute ihu thc above informatiun is
w � cortcc� I agrt:e to comply with all city and county ordinances and suk laws celadng to
0 U building consvuction, and hercby mUiori�e represemadvcs of this city w cnter upon the
� w ahove-menGoned property for inspenion purposes
a (Wc) agrce w save. indcmnify and keep harm�ess �he Ciry o[ Cupertino ageinst
�„E"", � liabilitiu, judgmcnls, cosls and expcnscs which may in any way acccuc againsl said City j
V z in conuquencc oC the granting of this permiG Date � ���'��
�"'� APPLICANT UNDERSTANDS AND WILL COMPLY WI7'H ALL NON-POINT Issued by:
SOUR LATIONS.
- `' Re-roof ; /�
i o(Applicam/Conlractor � T of Roof
HAZARDOUS MATERiALS DISCLOSURE YPe
Will ihe applicant or futurc building acupant uore or Aandle harardous matcrid
lefincd by the Cupertino Municipal Code. Chaptcr 9.12, and thc Hcalth and Safcty
�«� Section 25532(a)? �� All root s shall be inspected prior to any roofing material being installed.
❑ Ycs 1 bd r7o
✓� If a rool' is installed without first obtaining an inspection, I agree to remove
�11 the applicant or fuwre building accupant use equipment or Jevices which
emit Iwiardaus air contaminants as defined by the Bay Atca Air Quality Managemcn� all new materials for inspection.
�����
� y� �No
� `, ` ', 1���
Ihavcrea�iiheha�ardrnumaicrialsrequi�emcn�sundcrChap�cr6.95ofthcCali(or- j j �� / _��
nia Hcal�h & Safcry Codc. Scctioas Z5505, 25533 and 25534. I undctstand �hat iC �hc building �� � �
docs no� curtcntly Iwvc a mnan4lAu it is my rcsponsi6iliry W noufy ihc occupant nf thc Date
rey��re n;�a ,�,,,� x m�, P ,;o� a;�„� or. c�r�� or aN�r. •e of Appl icant
All roof coverings to be Class "B" or better
a horiic cn� D��
CITY OF CUPERTINO
4 ITEMS OF 24 PERMIT RECEIPT OPER.ATOR: SylviaM
COPY # : 3
Sec: Twp: Rng Sub: Blk Lot:
APN ......... 3�604025.01
DATE ISSUED.......: 11/21/2007
RECEIPT #.......... B:000003298
REFERENCE ID # ...: Oi110121
SITE ADDRESS .....: 2�398 MCCLELLAN RD
SUBDIVISION .......
CITY .............. CLfPERTINO
IMPACT AREA .......
OWNER ............. AI)AM WU
ADDRESS ..........: 2::398 MCCLELLAN RD
CITY/STATE/ZIP ...: CIJPERTINO, CA 95014-2753
RECEIVED FROM ....: F��ST WATER HEATER C
CONTRACTOR .......: J]�FF JORDAN LIC # 29100
COMPANY ..........: F��ST WATER HEATER
ADDRESS ........... 1:?601 132 AVE NE
CITY/STATE/ZIP ...: K:CRKLAND, WA 98034
TELEPHONE ......... (�300) 454-8955
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- --------
BSEISMICRE VALUATION 449.00 0.50 0.00 0.50 0.00
PPERMITFEE FLAT R.ATE 1.00 40.79 0.00 40.79 0.00
PRWHEATR UNITS 1.00 24.48 0.00 24.48 0.00
TRAVDOC FLAT R.ATE 1.00 40.79 0.00 40.79 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT : 106.56 0.00 106.56 0.00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- --------
518 WATER HEATER
From: 10116J2007 11:58 �787 P.007/012
. 379206 •
CITY OF CifP�R'I'Il�i()
WATER �[EATER
CUPEttTlNO �'ERMIT APPLI(;�1TIQ�T FORM oZ �
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�v # 2� � �� ' l.�-�J .- �r''
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Building A
2239 � ' , � � � � .
Owncr's Name: Phone #
� �� 408 887-8661
Cantractor: Phone #
FAST WATER HEATER COMPANY �-
Cupe�Rino Business Licxnse # State License #
29100 877489
gui�iding Permit Info:
Bl Elect h un Mech
Job Descripdon:
Remove/Replace Gas Water Heater
Residential $] Comm�ercisi ❑
Cost of Projec�
449.00
Strapped On Platfortn Bondod
New Location � ��� �
�' � Fe� Descri 'on Fee G
A licablc � ID
� PR'WHEATR Reudeatial Water Heater Neat BUII.DING
PCWI�EATR Camm�cacial WaberHesterlVent BITII.,bING
� PPfiRNIITPBE Pliunbing Permit Issuance PLtJMBING
� T�� � 3VCl 8t �tA[lOII � B���G
BUSLIC Bc siness License BUA..IDNG
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