00010042 .�APPLIC4NTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ppyy��
CITY OF CUPF,RTINO BUIL=G-ELECTRICAL PERMIT N0,
BUILDING DIVISION APPLICATION/PERMIT PLUMRING-MECHANICAL S.000�
NUILDING PROJECT IDENTIFICATION -
BUILDING ADDRESS // SANITARYNO. APPLICATION SUBMITTAL DATE
OWNER'S N ME: /PHONE: CONTR ,10k'S NAME: &alehIf NO:
WC
CON'IROLII
>RCHIT. ENGINE LI 'O: ADDRESS: / r/ ❑
CONTACT: PHONE, L 4 !N/ dU1LDINGPERMI'I INFO
/O Z�3 0/ ❑ Consallan Pe 5 d A plic' (Initial) yLDG ELECT PLUMB MFCH
❑ ❑ P", ❑
LICENSED CONTRACTORS DECLARATION QTY ELECT RIC PERMIT FEE
1 hereby affirm fi I I Teen: I u d p . of Chapter 9lcammenclny _ JOB DESCRIPTION
WOO nthS,, n]0001 of Summon 3.f`dm Ho,messandl fe..Ons Calc mA mylec x.s vERMI'1'ISSUANCI! RESIDENTIAL:
F W force and eRecL _ n ❑SFDWL ❑KITCHEN REMODEL
aUV Liana Chusl�Q—Lic.M •�--> APPLIANCES-RISSIUENTIAL ❑ADDITION El PLUMBING BE PIPE
F Z W Date Ci.5(4 �7 Contractor
w6C. ❑MULTI-UNIT ❑STRUCTURAL
ARCHITECT'S DECLARATION
PANELS MODIFICATION
Z,O91Z I understand my plans shall Fv axed u,+public records
OZ=—M UP'I'02W AMPS [I INTERIOR El CHIMNEY REPAIR
F�FW Licemed Pinessinnal 201-I0010AMPS IMPROVEMENT C]SWIMMING POOLS
C C G 1 hereby affirm OWNER-BUILDERthat I am xm�from the Contractor's
License Law for the OVER I000AMI'S ❑BATH REfs10DEUREPAIR DIih10L1T10N
C.0 fallowing reason.(Seminn]1131.5.Business and Professions Cale:any city or county SIGNS ELECTRICAL
El Oil
W'3 a,h which requires a permit to construct,aller,improve,demolish.or repair any sbndurc
I".u'�Q prior to its issuance,alno¢gaireN theapplicanl for Noah p.i,,o file asignN smmmem SPECIAL CIRCUI'T/MISC.
E y� thalmi,hearsedpursaam11.the provisions of the Contractors License Law, Chat9
V�1CCO (commencing with Section]1100)of Division 3 ofthe Business anJ Prnfcisinns Cwle)or TEMP.METER OR POLE INS'I'. ER AI:
d G c C CO
that he is exempt therefrom and the bu,i,for the alleged exemption.Any violation all ❑NI?W BLDG/ADDITION ❑DEMOLITION
m
Section 7031.5 by any npplicam fora permit suejemathe upplieam macivil penally eel' POWIiR DEVTCIII ❑TENANT El 1700D SERVICE
not mom than five hundred dollars 15500). IMPROVEMENT
I- 01.as owner of She prmpcnyc or my employees with wages as their sole compensation.peation. SW...VING POOL ELECTRIC
Lwill do the work,andthcaructure is a.,intended or offered for od,(Sec.]OYI.Business ❑OTHER
Iial w_ and Profex%ions Cale:The Contractor's License Law docs not apply to an owner of OUTLETS—SWITCHES—FIX
4"3 pmpony who builds or improve,thereon,and who docs such work himself of Ihnnlgl,
his own employees,provided dead such improvement,am not intended of ufiered for NHW RESIDENTIAL.ELECT PI'.
sale.If,however.the building or improvement is coldwiihin one year ofadidetiom.thc SQ.FT FLUOR AREA SISQ,FI'.
womer-muider will have the burden of proving that he did not build or improve for put.
pore of salcJ.
[3o 1,vs owner of the property,am exclusively cenvneting with licca.vl contractors m TOTAL:
ovum,the projeo(Sri.](W.Busiaens and Professions Cam
Cale:)The Commoi s Li-
vanse law doo,tr apply to an owner of property who build,or improvcs thereon,and QTY. PLUMBING PERMIT FEE
who commrls forsuch pmjems with a conoomods)licensed pummanuo the Conlracm(x se
License Law. YfiKMI"f ISSUANCE
E_1I am exempt under See .B&P C for this reason
ALI HIS-DRAIN h VENT-WAS ER IEA) VA WNI'SON
owner Dale n �O
WORKER COMPENSATION DECLARATION BACK FLOW vk01 CLT.DEVICE hereby affirm under penalty of perjury one of the follms ing doolamdionv 37
I have and will maintain a Cenificam of Consent to self-insure for Worker's Camper- DRAINS-FLOOR.ROOF AREA,COND. STORIES - '.TYPE,CONSTRUCTION
moon,see provided lirt by Scnian 3]111)of the Labor Gale,for the periismumar niche
work lin which this commit is i—ed. FIX"I ORES-PER'IRAP
❑1 have and will maintain Worker%Compensation Insurance,as required by Section
37M of the Labor Cale.fm the perm nan<cof the work for.1imli hia permit is i...ad. GAS-EA.SYSTE I.1 INC.S OUTLETS OCC.GROUP Q APN) 'J
My Worker' ensmion lgsuo '4 Pnlcy NmYn r,� X1)�0/v owl,
Cwrier: /✓ GAS-HA.SYSTEM-OVER1(EAl
CEKI'I FICATE OF EXEMPTION 1 SO M WORKI]NS' d� GRI:ASFANDUSTRI.WASTE INTGRCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed d da,permit is Simone hundred dollars(SI00) GREASETRAP _
rn PLANCHECK FEE
len.)
I comfy that in the performance ofthe work forwhich this permit is issued,l shall SEWER-SANT"TARY-STORM EA.204)FT.
not vatic,any perm any manner so as of e,on,.hjveI tons,Worker,'Cmn,a- ENERGY M?H
O Z cation Laws of Ca ilornia.Date WAS ER BEATER W/VENT/IiLIiCI'R GRADING FEE
Z O Applieam
G NOTICE:TO APPLICANT:If.offer making this Certificate of Exemption.you should WATER SYSTEMO BEATING SOILS FEF.
a , become Nubjecno the Worker's Compensation provisions of the Labor Calc,you must
forthwith comply with such provisiamof this pemit hallM deem ed revoked WATER SERVICE
Q
= z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM,. SQ.17. PAID Date Receipt p
V0 l hcrebyichaffirsoo his
SharenditI isxrn (Sar.30 len ding agency furthe peRormmce of
the work for which alis permit is issued 15ec.309].Civ.CJ
QTO"I'AL:
U LendAddNamc
Lnndor' Addtexs TOTAL:
I,
ccnify that 1 have read this application and slmc that the above information is BUILDING PCE
Fd
re, cormingcon«wricomply
and hereby city and county ntainuncesand nada enter
upon the QTY MECHANICAL PERMIT FEE
V z building conswainn.and hereby amhorine repreamvdivcs of min city men¢r upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(we)agree m nave,Indenimiy and keep hamdess the City of Cupertino against ELECTRIC FEE
Imbiblic..judgmems.ao.is mdexpenas which may,in any way acemcagai....aid Cil, ALTER OR ADD*10 MECH,
PLUMBING FF.F.
at nICANTe thegraining of Ipenned.
N
APPLICANT UNNAND NU WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FT:f:
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER IB.(XIUCFM) CONS'ikUCTION"ITA%
Sigemmrcof AppliesntaCuntracmr - Data EXHAUST 11001)(WMUC) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Willdw.,licunt or name building occupant%rare or handle hvaNnus material HEATING UNIT DID 100."BI U)
as defined by the Cupertino Municipal Cale.Chapter 9.12,and the Hcahh and Safely
Cndc,Section 255321u1"
HEATING UNIT(OVER 100,000 BTU)
[:I ye, ❑Nn PAID —
VIiNTILATION PAN[SINGLE RL'SIU) pate RcceiplM
Will the applicant or future building occupant use equipment or devi ev which BOIL —
ERCOMP IJHP OR ISILDSO BTU)
mit hazardous air contaminants as defined by IM Bay Area Air Quality Management TOTAL: 75
DL"Ito❑Y �Nn BOILER—COMP(OVER I B(jft IST Dia,
I have rwdlhc harudous mamregmre
riWN Is under Chapmr6.95 oflhe Cali- AIR CONDITIONER / / ISSUANCE DATE
cit
fomia Health&Safely Code,Sections,In.,i is my and 25531.1 to ran,She
low if the NEW RESIDENTIAL MECH. SQ.FI'.
building donsneercurrency have ammni,tkutid ism,we of a errymnotifythepancy. _
nfrhv rcyuirements whmh nmst be mal prior to issuvnce of u Caniyeum of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: christya
Ser. Twp: Rng: Sub: Blk: Lot:31602031.00
INVOICE DATE...... : 01/11/2000
REFERENCE ID N ... : 00010042
SITE ADDRESS ..... : 10628 LARRY WY
SUBDIVISION .......
CITY ..... . . ......: CUPERTINO
IMPACT AREA . ......
OWNER ......... .. . : KUO MAN N NANC
ADDRESS .......... :
CITY/STATE/ZIP ... : SAN JOSE CA, \A 95134-1908
CONTRACTOR ....... : GILROY, JOHN LIC # 15128
COMPANY . ......... : JUST WATER HEATERS INC
ADDRESS .......... : 1764 NATIONAL AVE
CITY/STATE/ZIP ... : HAYWARD, CA 94545
TELEPHONE ........ : (510)293-9901
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BPWHEATER P 9.99 0.00 9.99
PPERMITFEE P 35.52 0.00 35.52
--------- ------------ -----------
45.51 0.00 45.51
V ID DESCRIPTION VOICE ID -_...._ DESCRIPTION
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
JRN. 10.2000 10:09AM NETCLERK INC NO.E93 P.10
CITY OF CUPERTINO
BUILDING PERMIT APPLICATION
10300 Torre Ave. Cupertino,Ca. 95014
(408)777-3228
PROJECT ADDRESS; 10628 Larry Way BLDG# SUITEIAPT#
PROPERTY OWNER CONTRACTOR
OWNERS NAME: Dong,Wuxing NAME,lust Water Heaters Inc
MAILING ADDRESS:10s28 Larry Way MAILING ADDRESS: 1764 National Ave.
CITY/STAT6RIP: Cupertino, CA 96014 CITY/STATEOP: Hayward CA 94545-1722
PHONE#:( 408)257-2575 FAX#: ( ) PHONE/..( 510)293.2012 PAX 0: ( )
E-MAIL ADDRESS: E-MAIL ADDRESS:permitoWustwaterheaters.net
bL 0 S 1 BUSINESS LICENSE!.. 15128
EXPLAIN FORK TO BE PERFORMED; Water Hester Replacement 40 Gallon Gas
BUILDING: E[.ECTRICAL: MECHANICAL: PLUMBING: be
RERCOF: HAZARDOUS FORE ARSA: YES NO_ NUMBER OF EXISTING ROOF COVERINGS:0
TYPE OF EXISTING ROOF COVERING: PROPOSED ROOF COVERING:
NUMBER OF EXISTING ROOF COVERINGS REMOVED: 0
NUMBER OF EXISTING ROOF COVERINGS RETAINED: 0
PROVIDE LCA.0.REPORT NO, VALilATION; 939.00
• IMPORTANT NOTICES NOTICE TO APPLICANT
APPLICANTS CERTIFICATION I hereby affirm under penalty,of perjury one of the fallowing declarations:
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ( ) L I have and Wit malmaM a certifroste of consent to seKinsure for worker corlr-
ABOVE INFORMATION IS CORRECT.I AGREE THAT IF A PERMIT IS IS. pereadon,ee Provided by section 3700 of the Labor Code,for the pedormmnco
SUED FOR THE DEMOLITION DESCRIED IS THIS APPLICATION,ALL THE of the wk which this permit Ia Issued,
PROVISIONS OF THE PERMIT AND ALL LAWS AND ORDINANCES (I) Q. I hew and will maintain workem'compare iti n Insurance.as Met ulmd by Seo-
THERTO WILL BE COMPLIED WITH. don 3700 of the Labor Code,for the performance of the wear for which this
permit Is issued, W cookers'compensation Insurance carrier and policy num.
HOLD HARMLESS CLAUSE.The parmitee(a)by acceptance of the permlL Capt Clarendon
agree(s)to Indemnify and hold harmless the City of Cupertino from and
against any and all claims,demands and actions for damages resulting from Polley Number 02KR000IO18
operations under this permit,regardless of negligence of the City of Cupertino
against all such Claims,demands or actions. O at The mat of the work done is 1100 or Iced.
In conformity with the provisions or Section 3800 of the Labor Code of the l ) Iv t carry that In the performance or IM work for which this permit Is Issued.I
State of California.the applicant shall have coverage under(I),or(II)desig- shall not employ any person In any manner so as to become subject Io work-
rated below or shall indicate Items(IID•or(M or M.whichever is applicable, are'mmpsnwtion Iowa of CellforNa.I further acltnovvIedge that I underatend
If however Item M Is checked item(IV)must be chocked as wall.Mark the that in the ewntthat I should become subject re the worker compensation
appropriate method of compliance. pravislons of she Labor Code of Ceiifomla and fail to COM"forlhwllh with
Provisions ol Seetlon 3800 of the Labor Code.that the same herein applied is,
shall be deemed revoked.
LICeN860 CONTRACTORS DECLARATION
I hwaby aahm that I am a rim under me proNeons of chapter I(mrmrsndng with ( 1 v. I early as the owner(or the agent for the owner)that In the pe foil of the
04mon7cmi or oi.idon s d the euekwa and Prdaaslore ems.ale myrimw Isi,fW Mq and
i work for which this permit is it aued,I will employ a contractor who complies
wall the woks'compeneaeon laws of California and who.prior io the cmv
Uesnee#591329 Claes C36 B Sr 03/31/2000 mantlement of any work,will 01e a completed copy of this form with the Conbel
Permjl Buroeu.
PAYMENT
ACCOUNT M 7 ) EXPIRATI N DATE:
CREDIT CARD TYPE -r NAME ON CARD: Inc-
JrRE: AMOUNTS:
DEC g g -rt(�
Scott WatP.rb.u•ny
Signanol'Appu slid - DATE Printed
L '
: ZAN.10.2000 10:06AM NETCLERK INC 140.1393 P.9
880 Dubuque Avenue
NetClerk, Inc. : e-solutions for the contracting industry South San Francisco, CA 64080
(888)88 CLERK
AnkBuilding Permit Ap lication
rom: NetClerk Inc. To: Building & Planning Department
Contact Name; Scott Waterbury City; Cupertino
Phone: (650)624.0426 Phone: (408) 777-3228
Fax Number: 1-(877)846-5888 Fax Number: (408) 777-3333
Permit Handling Instructions
Please Fax Permit to: 1-(877)8465888 Deliver to Job site at first inspection
I will pick permit up at the Building Department in 5 days HxPlease mail to Contractor address below
Other: please email permit to: permib@netclerk.com
Contractor Information
Company: Just Water Heaters Inc. Worker's Comp M 02HR0001018
Contractor: Attn:Arnold State Contractor's License# 591329 ClassC-36 B
Address: 1764 National Ave. Credit Card Information
City: Hayward,Ca. 94545-1722 Credit Card Number: 5474-6331-7168-6326
Phone: 510-293-2012 Name on Card: Just Water Heaters Inc.
Fax: 510-783-6360 Expiration Date; 09/02
AsI: permits@justwaterbeaters.net Visa MasterCard X�
Comments:
Authorization forms:
Credit CtiMAuthorization Form •AgantAatlwWaelmr-8ycnmpkangandrenaningdrehdorrnadonbelow,
you audwrtte Netaedc Inc,to act as an agera on your belugfer the purpose
ofsubmlNng Pei nit appocudorm
�f WMSq-tl krrB>s' Islt to WhgaRA4yConearn;
Pas tgtthhhlwaadrOrtarfretdeHplrre andAsempbyeesand
am.a: '. aa�wrlmd�,suodar�s reactas an agemonowhenad'-ypMngforany
tPJtet ly.. li�"KVI EIVWY'ui.Ytr "'fI *hian(♦''bL'1n52S'IaQ. awcornissr .
prinuid
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a�olnNelcmdpa'�dhmd 1klbPioper�tpma <�5. >ti r';. .
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