08120060 CITY OF CUPERTINO ,; A7�'Fsxc&m.:rxd: i
BUII,21'NO DI IISION PERMIT aepw"R OR'INF0 MATMON "y>;
BUILDING ADDRESS: - PERMIT NO.
7668 NORMANDY WAY HOME DEPOT
OWNER'S NAME: PERMIT LSUE DATE
C'RTTM T,,ITTT ART) T AND lR4ARTl5N 32601 132ND PATE NE;
NE:
A 0. CONTROL NO.
(425) 636-7054
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUM0B MECH
o C 0
go, LICENSED CONTRACTOR'S DECLARATION Job Description
I V� 1 bmeby v(fitm tial I.m licened under provisions or Chapter 9(rommcnem,
with Scedon 70p0)efDivision 3 of Oc Businm aM Pro(rasioru Code.aM my licene u
70� In full to=and effx REPLACE GAS WATER HEATER ,
51RIZ L..Class Lk.x
E;: Dass: Conumar
p�p ARCHI'IERSDECLARATION
C 1 mommoad my plans shall k used as Public rcemtls
U
;o
of Licemed Pmfesdonal
5 OWNER-BUILDER DECLARATION
ComusON
1 hereby.stm o n I sm exempt from the Casino o LiMy c Law for Ote
C 5 following lesson.(Sone n exa Business and rte.theism Code:Any city m county
which requires n permit re comvset aper,improve,de permit
t fi repair ed smnun:
=es duu.W itaissucodpurmontto rte tkvissom of far suchpermitmfilcn:signedstatement
thabeucing with
purstion to the 9 Division
of tate Coeuacros and Professions
(ChapterCode)or Sq.FL Floor Area Valuation
yFZ-� (comets exe'ndiSriont(and of Diviason3 afdc Busineasarm Prof tore Godc)or 449
.Nat k u exempt therefrom and Ne Ouu for tate illeged exemption Any violation Of
Scedon 7031.5 by any applicant for a permit subjects the appkant to a civil penalty of APN Number Occupancy Type
not mom than five kMmd dollars(150(y. 36617054 . 00
0 I.sa owner of use prop stry,m my c nployeas with wages as their cele compensation,
will do the work.and the structure is ram Intruded or offered for We(Sec,70N,Business
sent Cede late Conusmns
Ys License law does Out apply m n owner, Required Inspections
d R
pmpeny who builds or im proves thneem,and who does such wort himself or through his
awn employees,provided tion such improvementa are not intended oroffern l forsale.Ir.
however.the building or Impmvemant Is sold within one year of completion.the wner-
builder will have do tandem of proving that be did ret build or improve for purpose of
sakJ.
0 1.R,nam of tate property.we eaclutively convecting with licensed cenvacmrs or
e custmm the pmjen(Sm.7054,Business and Prefesdans Cede:)M Cmrc amofa Li-
exam Law dors not apply ro sn owner of property who builds or improves thereon,and
who convexts tut such pmjcm with a conwcmr(s)ficemed pum ons In the Contnetefs
Lhamen raw.
0 1 am exempt under Sec. .B d P C for dus won
Owner Dam
WORKERS COMPENSATION DECLARATION -
1 hereby alBm under penalty of perjury ane of the following declanuoas:
I haw and will maintain•Certificate of Constant w ret(-imure for Warkeh Compeo-
ion,u provided for by Section 3700 of Be labor Code.for the Performance of the
wmic for which this permit is Wood.
0 I have and will maintain Wmkeh Cc mpnuadnn insurance,as mgtured by Section
3700 of But labor Cache.for the performance of the work for which this permit is issued.
My WorkeYs Compensation iwrtan¢carrier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu scoms need trot W completed if the permit u fmmnc hundred dollars(1100)
or leas)
1 certify that in the Mr..of the wart for which this permit is issnetl.l mail not
employ any person in any mannerm as as become subject to the Worl cn'Comperwuon
Laws of California.Date
Applicants
NOTICE TO APPLICANT:If.after making this Certificate of Eaempuon,you should
become subject OR the Worker's Compensation provisions of the labor Code,you most
O foMwiN comply with Ruch provisions or this permit shill he dcsmcd rooked
Z DilCONSTRUCTION LENDING AGENCY
[-+ Ik¢by.M.that titem is a eonsuactimn kndingagemy,for Ne perfurmatceof
C > the work for which this Permit u issued(Sec.3057.Civ.Q
ul Q LcnderR Name
CL,.7 z Under,Address
U O I mttify th.,1 have read thio application and sere the the.hove information is
correct.I agree to comply with all city and county ominances and Ru¢laws relating In
0 U building convection,and bomb,auhodm mprommdva of this city to enter upon the
apove-mentimcd property for inspection purlroaes
Fy (We)agree to save,indemnify and keep harmless the City of Cupertino against
rq liabilities.judgments,costs and c.,.which may in any way accrue.,.lost said City
U Z
in consequence
of the Swung Of this portonAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signaum of AppliaHAZARDO Date
HAZARDOUS MATERIALSDISCLOSURE Type of Roof
Willy the Cupertino
or Tatum building e.Chapter
nom or handle Health
material
' u defmN by the Cupertino Municipal Code.(3apter 9.13,and tite Halth and Safety '
Cade.Section 3553I(a)7 All roofs shall be inspected prior to any roofing material being installed.
CYa ONO
Will Be applinnt or future building omrpam useequipmmn m devices which If a roof is installed without first obtaining an inspection,I agree to remove
II huvam..'.I,contaminants u defined by the Bay Arta Air Quality Management all new materials for inspection.
m ct9
0Ya ON. y
I have mad theha ma
aardnterlal,roquimmenu under Chapar&95 of the Caiifor-
hiaFka["Safay Code.Sautats3550.5.35533a M34.1u cannot dwifthe building
dao not eamendy haw a Intim,BULL it u my raporuibility In neufy the occupant of do
requirements which must W met pnorth issuance ofa Certificate of Occupancy. Signature of Applicant Date
Owner Or an h.d ed.Sent Date All roof coverings to be Class'W'or better
A
• CITY OF CUPERTINO
4 ITEMS OF 28 PERMIT RECEIPT OPERATOR: suew
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36617054 . 00
DATE ISSUED. . . . . . . : 12/04/2008
RECEIPT #. . . . . . . . . : BS000006760
REFERENCE ID # . . . : 08120060
SITE ADDRESS . . . . . : 7668 NORMANDY WAY
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CRUM WILLARD L AND MARIAN J
ADDRESS . . . . . . . . . . : 7668 NORMANDY WAY
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-5253
RECEIVED FROM . . . . : JEFF JORDAN
CONTRACTOR . . . . . . . : FRANK BLAKE LIC # 30610
COMPANY . . . . . . . . . . : HOME DEPOT
ADDRESS . . . . . . . . . . : 12601 132ND AVE NE
CITY/STATE/ZIP . . . : KIRKLAND, WA 98034
TELEPHONE . . . . . . . . : (425) 636-7054
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
--------- ------------- -------- --------- --------- --------- ---------
1BSEISMICR VALUATION 449 . 00 0 . 50 0. 00 0. 50 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 .00
1PRWHEATR UNITS 1 . 00 24 .48 0 . 00 24 .48 0 . 00
1TRAVDOC FLAT RATE 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
Community Development
. 10300 Torre Avenue
j� Cupertino CA 95014
Telephone(408)777-3228
OF Fax(408)777-3333
OCUPEkTINO
Building Department
JOB ADDRESS: 7668 NORMANDY WAY PERMIT# /ti p/�
ME: ala/
OWNER'S NACRUM,WILLARD PHONE # (4018/)2503-2277 C!�
GENERAL CONTRACTOR HOME DEPOT FAX# 425-814-9516
I am not using any subcontractors:_ C'�.w �Lc ,�aQP 1114108
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 Date
Permit No:
Ogl d00k 000000
(office use only)
• City Of Cupertino Building Permit Application
E-Mail: Building-Permits(a)-cupertino.org (Address is case sensitive).
Jobsite Address:7668 NORMANDY WAY Date: 144108
Assessor's Parcel Number: giW l�a
Owners Name: CRUM,WILLARD Phone No: (408)253-2277
Project Valuation: 449.00
Building Permit Info: Bldg Elect Plumb x Mech
Job Description
Remove/Replace Gas Water Heater
Contractor Information
Company Name: HOME DEPOT Phone No:
• Contact Name: Carol Randall Fax No: 800-454-8955
Address: 12601 132ND AVE NE E-mail: carolr@fastwaterheater.com
City, State & zip code: KIRKLAND, WA 98034
State Contractor's Lic. No: 602331 Expiration Date: 9/30/9
Worker's Comp No: 1928756 Expiration Date: 3/1/09
Carrier: AMERICAN HOME ASSURA
City of Cupertino Business License No: 1Q,..
Credit Card Information
Credit Card No: Expiration Date: 11/10
Name on Card: Jeff Jordan
Visa ® MasterCard ❑ American Express ❑
• The Building permit application and a completed & signed
contractor/subcontractor form need to be submitted with each permit.