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10110114 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22240 VARIAN WAY CONTRACTOR:ATLAS-TRILLO HVAC PERMIT NO: 10110114 OWNER'S NAME: SHANKAR 1965 KYLE PARK CT DATE ISSUED: 11/17/2010 OWNER'S PHONE: 4089814594 SAN JOSE,CA 95125 PHONE NO:(408)286-8931 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ REMOVE AND REAPLCE EXISTING WATER HEATER IN License Clas # 3 71 EXISTING LOCATION Contractor. 0 Date I hereby affirm tha Incense under the provisions of Chapter 9 (commencing with Secti 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations. Sq.Ft Floor Area: Valuation:$3000 1. 1 have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the APN Number:32617043.00 Occupancy Type: performance of the work for which this permit is issued. 2. I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. PERMIT EXPIRES IF WORK IS NOT STARTED APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR I certify that I have read this application and state that the above information is 180 DAYS FROM LAST CALLED INSPECTION. correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter 7 upon the above mentioned property for inspection purposes. (We)agree to save Issued b Date: ! —G1� indemnify and keep harmless t Cupertino against liabilities,judgments, costs,and pen -which y accrue a 'nst said City in consequence of the granting of is ermit. A itionall , e licant understands and will comply with all non-poi so c re ul tions a th u no Municipal Code,Sect' 9.18. RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is Signature Date_ installed without first obtaining an inspection,I agree to remove all new materials for inspection. r, OWNER- UILDER DECLARATION Signature of Applicant: Date: ._reby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER the following two reasons: 1. 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 HAZARDOUS MATERIALS DISCLOSURE sale(Sec.7044,Business&Professions Code) I have read the hazardous materials requirements under Chapter 6.95 of the 2. I,as owner of the property,am exclusively contracting with licensed contractors to California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain construct the project(Sec.7044,Business&Professions Code). compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Section 25532(a)should I store or handle hazardous material. I hereby affirm under penalty of perjury one of the following three declarations: Additionally,should I u uipment or devices which emit hazardous air 1. 1 have and will maintain a Certificate of Consent to self-insure for Worker's contaminants as deli d by he Bay Area Air Quality Management District I will Compensation,as provided for by Section 3700 of the Labor Code,for the ma' tain complianc w' Cupertino Municipal Code,Chapter 9.12 and the l performance of the work for which this permit is issued. He th ety C ti s 205,25533,and 25534. 2. I have and will maintain Worker's Compensation Insurance,as provided for by O nc o ent: Section 3700 of the Labor Code,for the performance of the work for which this Date: 0171 permit is issued. 3. 1 certify that in the performance of the work for which this permit is issued,I shall CONSTRUCTION LENDING AGENCY not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I I hereby affirm that there is a construction lending agency for the performance of work's become subject to the Worker's Compensation provisions of the Labor Code,I for which this permit is issued(Sec.3097,Civ C.) Lender's Name must forthwith comply with such provisions or this permit shall be deemed revoked. Lender's Address APPLICANT CERTIFICATION ARCHITECT'S DECLARATION I certify that I have read this application and state that the above information is I understand my plans shall be used as public records. correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter Licensed Professional upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ling of this permit.Additionally,the applicant understands and will comply with n-point source regulations per the Cupertino Municipal Code,Section 9.18. Signature Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: suew COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32617043 . 00 DATE ISSUED. . . . . . . : 11/17/2010 RECEIPT #. . . . . . . . . : BS000012036 REFERENCE ID # 10110114 SITE ADDRESS . . . . . : 22240 VARIAN WAY SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . . SHANKAR ADDRESS . . . . . . . . . . : 22240 VARIAN WAY CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-1065 RECEIVED FROM . . . . : ATLAS TRILLO CONTRACTOR . . . . . . . : TRILLO, STEVE LIC # 4269 COMPANY . . . . . . . . . . : ATLAS-TRILLO HVAC ADDRESS . . . . . . . . . . : 1965 KYLE PARK CT CITY/STATE/ZIP . . . : SAN JOSE, CA 95125 TELEPHONE . . . . . . . . : (408) 286-8931 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 3, 000 . 00 1.00 0 .00 1. 00 0.00 1BSEISMICR VALUATION 3, 000 .00 0.50 0 .00 0.50 0.00 1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0.00 1PRWHEATR UNITS 1 . 00 25. 00 0 .00 25.00 0. 00 1TRAVDOC FLAT RATE 1 .00 42 . 00 0 . 00 42 .00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 110.50 0 . 00 110 .50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 110.50 2440 --------------- TOTAL RECEIPT 110.50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 518 WATER HEATER CITY OF CUPERTINOOF WATER HEATER CUPEkTINO PERMIT APPLICATION FORM APN # /,� 10 Date: ( -7 L10 Building Address: 2ZZ A-�J Owner's Name: Phone #: Contractor: i j &FT � C Phone #: Fax #: ,Z Cupertino Bus' ess Lic nse #: Contrac or Sta License #: dal 57 Contact: KalLy � �6 S Phone #: t ZC� j,/ v Fax #: Building Permit Info: Bldg ❑ Elect ❑ Plumblo Mech ❑ Residential Commercial ❑ Job Description: �� -- �� `� I ISTI N Strapped ❑ On Platform ❑ Bonded ❑ New Location ❑ Replacement Valuation (cost of project): �b-t7o --- Project - -.—Project Size: Express ❑ Standard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Green Building Points achieved: Revised 03/10/10