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06100095 CITY OF CUPERTINO BUILDING rAVISION PERMIT BUILDING ADDRESS: WATER HEATERS ONLY PERMIT"°. 0 610 0 0 9 5 19979 RODRIGUES AV PERMIT ISSUE DATE OWNER'S NAME: STEVEN CHASE 970 E. MAI SANITARY NO. CONTROL NO. NE: (800).835-5946 BUILDING PERM(TINFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH 0 p C LICENSED CONTRACTOR'S DECLARATION Job Description U I hereby affirm that I am licensed under provisions of Chapter 9(commencing z with Section 7000)of Division 3 of the Business and Professions Code,and my license is "C in full force and effe r�'3 3 7 15 7 3 REMOVE AND REPLACE WATER HEATER ;MCA ? Liccnsc Lic.S i F� Date ontraclor ARCH S D O i a< 1 understand my pia lie c dl>!.yt _��'^"'"s-� >teU .a Oy Licensed Professional CA OWNER-BUILDER DECLARATION 3< I hereby atTirm that 1 am exempt from the Contractors License Law for the 00 following reason.(Section 7031.5,Business and Profcssions Code:Any city or county %m which requires a permit to construct,alter,improve,demolish,or repair any structure r Z prior to its issuance,also requires the applicant for such permit to rile a signed statement $q.Ft.Floor Area Valuation _ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 t-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or r that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of T 0 Occupancy Type not more than five hundred dollars($500). ❑1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale.If, however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did riot build or improve for purpose of sale.). ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. ❑I am exempt under Sec. B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. tohaveand will maintain Worker's Compensation Insurance,as required by Section loo of the Labor Code,for the performance of the work for which this permit is issued. My Worker's 4CERRCAETEOFREXEM . nd Policy qugbe(r -3 49 _O Carrier. olity No.:(� ON FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued,1 shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must 2 forthwith comply with such provisions or this permit shall be deemed revoked. z O CONSTRUCTION LENDING AGENCY Er►CA-� I hereby affirm that there is a construction lending agency for the performance of R;> the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lender's Name �Z Lcndees Address U C-) 1 certify that 1 have read this application and slate that the above information is LL correct.I agree to comply with all city and county ordinances and state laws relating to O Ubuilding construction,and hereby authorise rcpresentalivcs of this city to enter upon the above-mentioned property for inspection purposes. a (We)agree to save,indemnify and keep harmless the City of Cupertino against „Fcliabilities,judgments,costs and expenses which may in any way accrue against said City IJ z in consequence of the granting of this emit. Dace L APPLICA NDERST DS WILL MPLY WITH ALL N N-POINT Issued by: SOURCE ULA ) 2- D �. 1 d � L Re-roofs Signature of Applicant/Contractor Date Type of Roof HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(x)? 6,W— All roofs shall be inspected prior to any roofing material being installed. ❑Yes If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. District? ❑Yes [ I 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that ifthe building does not currently h vc a tenant,that it is y responsi hil itytonotify the occupant of the requirements �ttutbcme 'o r an«era nificateorgrct ancy. Signature of Applicant Date �,�._�� 1 Z 06 All roof coverings to be Class"B"or better authorized Owner or horized agent Date Community Development 10300 Torre Avenue &CM Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 - TERTINO Building Department JOB ADDRESS: PERMIT# lg � oo OWNER'S NAME: V PHONE# 19L S 7 -3 GENERAL CONTRACTOR: ,Q FAX# I am not using any subcontractors: LJa& /uc )0// d 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 CITY OF CUPERTINO am 1 of 2 PERMIT RECEIPT OPERATOR: amyw COPY # 2 Sec : Twp: Rng: Sub: Blk: Lot : APN 36904008 . 00 DATE ISSUED. . . . . . . : 10/12/2006 RECEIPT # . . . . . . . . . : 36421 REFERENCE ID # . . . : 06100095 SITE ADDRESS 19979 RODRIGUES AV SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : STEVEN CHASE 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 FEE 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 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ----------------------- 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING aac()95 CITY OF CUPERTINO WATER HEATER ..UPEfkTINO PERMIT APPLICATION FORM APN# Date: L o J Z�o G Building Address: Owner's Name: Phone#: 2,5 7 -33 3 O Contractor: Ph ne: License#: Ph ?()U S-S9gi 374S -7 3 Contact: Phone: Cupertino Business License#: Building Permit Info: Bldg ❑ Elect Plumb Mech Job Description: /e-- 4 � Residential Commercial ❑ Cost of Project: �- /�?00 `rapped On Platform El Bonded ET New Location ❑ Re lacement x Qty. if Applicable Fee ID Fee Description Fee Group BPWHEATER Water Heater/Vent BUILDING I PPERMITFEE Plumbing Permit Issuance PLUMBING BENERGY Energy BUILDING BUSLIC Business License BUILDING