06070169 (2) CITY OF CUPERTINO d'e- Ter ai 5 k €-! a
BUILDING DIVISION PERMIT 9 CONTRACTOR�TNFORMATION -:
BUILDING ADDRESS: a WATER HEATERS ONLY "fiRmff"°.06070169
21940 RUCKER DR
OWNER'S NAME: PERMIT ISSUE
DATE
DONALDSON, SUSAN 970 E. MAIN ST SUITE 2 25/2006
NE:
SANITARY NO. CONTROL NO.
(800) 835-5946
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Op LICENSED CONTRACTOR'S DECLARATION lob Description
i U Ej1 MrebY+farm that I am licensed unit,provisions or Chapter 9(rommcncing
with Section 70110)of Division 1 of the Business and Professions Code,and my license is
j inmBfame and off= (g. L 74 REMOVE AND REPLACE WATER HEATER
nqz License Class
p
Dole mux
4
ARCRO TI
i y I understand my plans sha rte and as public C.'aft
iyu
'a t; Licensed Pmfassianal
3 OWNER-BUILDER DECLARATION
E I lec¢by slum Nat 1 am aumal from Ne Comranors License Law far tW
%G O following mason.(Section 7031.5,Business and Predications Codc:Any city or County
%$_rE which require a permit to consume,alcor.improve,demolish,Or repair any suunurc $1000
i prior W is issuance,a enquires tW applicwt forsuch permit W file a signed sumnmm
< Nat he I,licensed pu=.ImNeProvisions ofamComantofsLice=Law(chapter 9 Sq.Ft. Floor Area Valuation
`ZF$ (commencing with Section 7")of Division l of the Businmand Professions Code)or
_. that he u exempt therefrom and the basis for the mlcgcd exemption Any violation of
Section 70113 by any applicant for a permit subjects Cont applicant W a Civil penalty of
Occupancy Type
not mote Nan fon hundred dollars 13300).
❑I.as owner of the property,or my employees with wages as their aide compensation,
will do the work,and Ne nSucmre u nil intended or offered for sath(Sec.7614,Businume
and Pmrassimes Cade:The Contractors Likerne law Class nut apply W an owner of Required Inspections
progeny who bailor Or consomme Nemoa.and won daessuch work himself w Luromgh his
Own employ=.provided that such improvenu na art tml intended or offered forsale.If. /
however,Ne building or improvement is Gold within ane year of cnmplcoon,the owner.
Wilder will Tuve the burden of proving Nat he did Out build or improve far purpose of
seilJ.
❑1,as owner of dm property.am exclusively contracting with licroscd conmcmrs W
Construct Ne project(Sec.7044.Business and Professions Code:)The Connector's Li.
ceaselaw does not apply jean owouwith
orprogeny who seillsorimPrams Norton,and
who conLaw.for tach projects with a ronvecWr(s)licensed pursuant W the CannxWrs
0
License an law.
❑lam uempt under Sea .B&PCfor this mason
Owner Date
WOR KER'SCOMPENSATION olDECLARATION
1 borebY aRnv under pcnilty of perjury as of Neffollowing dalarstioes: D
1nam ono will for by Section
37M of live
Lahr Code.for performance
of the
moan,as provided fon mi Ss ism 1]00 a(Ne Labor Cade,far dm per/oman¢of the (�
work far which Nu permit u issnted.
Ithave and will maintain Workkri Compensation Insurance,as required by Section
of an,Labor Cook,for the performance of the work fon which this permit is issued. '
MyW sCampensvion nsuran W/,rt)y/�r{ap�nA�Policy runner am:
Cartier c•`7j;;my No.: 44503•'V `
CERT CATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
menses tion need Out beeompleted iftho permit s feronc hundred dollars(SIM)
or less.)
I Certify Nat in the pef amemen of mho work for which this permit u issuce,I shall hat
employ any Person in my manncrse as to become subject to Ibe Worker'CompcmaBon
Laws of Califomia.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cenifcale of Exemption,you should
become Subject W the Worker's Compensation provisions of don labor Coda,you most
.,z forthwith comply with such provisions or this permit shall be accrued mmkcd.
z '-' CONSTRUCTION LENDING AGENCY
C7
[—n hereby which hiNmthem iseod(Socl3097.loading agency for are Performance of
eL > Newark Thr worm th�Dkrmn fr ivaa(sok.7(197,ci.,c.)
CL O anda a Nam
=) z I.cndars Aaam•.
V C) 1 certify Nu 1 have read his application W sum than the above informadun is
gL, Correct.l agree to comply with all city and county ordinances and mm laws relating to
O V building construction.and hereby amhoriae mpmxnutimes of Nis city to cnmruMn the
r W mo.e.mentimed property lar inapeetiam purpwns.
gy (We)agree octave,indemnify and kap bumless the City of Cupertino against
mF.py limilities,judgmena,coxa and expenses which may in any way see=agamal mid City
V z in consequence of the granting of this permit.
^ APPLICANT ERSfAN A ILL CO PLY WITHA NON-POINT Issued by: Date
SOURCE R LATIO
`"""�� /O t Re-roofs
Sig....of Applican✓Canoactor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Luc applinnl or future Wilding occupant start urhandlc hicudous material
as deBxd by the Cupertino Municipal Code.Chapter 9.11,and tho Hums and Safety
Cadc.Section25512(a)] All roofs shall be inspected prior to any roofing material being installed.
41 ❑yes t Na
If a roof is installed without first obtaining an inspection, agree to remove iection,I
Will the applicant or furore Wilding occupant arc equipment or devices which P
omit harardn is it cmnaminonts u defnncd by the Bay Area Air Quality Management all new materials for inspection.
D svim4
❑Y
I have mad N<hamAous am mnotbacquiremens under Chmetr6.95 ofthe Califor
-
niaHcalrh&Safely Cada,Savor 25505,25577 md125514.IwdarsaM mhmifthk Wilding
docs nos cu dy have a it u my amNili y he notify Nk..P.O or Nc
mymim whish wl rmissa 'ar.ck14rmamarOrscu Signature of Applicant Date
l'' w All.roof coverings to be Class "B"or better
Owner w authori>cd ager Dam
CITY OF CUPERTINO
�m 2 of 2 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35614022 . 00
DATE ISSUED. . . . . . . : 07/25/2006
RECEIPT 4 . . . . . . . . . : 35375
REFERENCE ID # . . . : 06070169
SITE ADDRESS . . . . . : 21940 RUCKER DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : DONALDSON, SUSAN
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : BONITA JENKINS
CONTRACTOR . . . . . . . : MCGEE, PAT LIC # 18986
COMPANY . . . . . . . . . . : WATER HEATERS ONLY
ADDRESS . . . . . . . . . . : 970 E. MAIN ST, SUITE 200
CITY/STATE/ZIP . . . : GRASS VALLEY, CA 95945
TELEPHONE . . . . . . . . : (800) 835-5946
�EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ---------- - -- ---------- ---------- ---------- ---------- ----- -----
BENERGY PERMIT FEE 1 . 00 34 . 86 0 . 00 34 . 86 0 . 00
BPWHEATER PER HEATER 1 . 00 10 . 79 0 . 00 10 . 79 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00, 38 . 37 0 . 00
------ - - - - ---------- ---------- ----------
TOTAL PERMIT 84 . 02 0 . 00 84 . 02 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ---------- - -- - ----
OTHER 330 . 88 VISA
TOTAL RECEIPT 330 . 88
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
Community Development
10300 Torre Avenue
j Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
%KkI INO
Building Department
JOB ADDRESS: Z-/ ? vo PERMIT�6 G ? 0(6f
OWNER'S NAME: a P PHONE # —3 3
GENERAL CONTRACTOR Q FFAX #
I am not using any subcontractors: l r� /44yoINA
Signature Date
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
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature bate
CITY OF CUPERTINO oo Iu
WATER HEATER
6UPEf�TINO PERMIT APPLICATION FORM
APN# Date:
7/3_S,/o J�;
Building Address: Z! q 4lo v
n -
Owner's Name: nn Phone#:
Contractor:/, 1 Phpne: License#:
?OJ F35-5946 3 7 c4 s 7 3
Contact: Q Phone: a��_ Cupertino Business License#:
�D7- c✓ /
Building Permit Info:o: 9?6
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: /e.,- KJ
Residential Commercial ❑
Cost of Project: o0
apped On Platform Er Bonded
New Location ❑ Replacement
Qty. if
A licable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
I PPERMPI'FEE Plumbin Permit Issuance PLUMBING
/ BENERGY Energy BUILDING
BUSLIC Business License BUILDING
•