07100090 CIT�' QF CUPERTINO � � T �q� 7� At
BU[LDING DIYI�ION PERMIT �.+����'"�O� y����r'��T�tQ�.l4 '
::....: ; _._.... ,:
PERMIT NO.
BUILDI �c�q���.ssEMPIRE AVE FAST WE�TER HEATER 07100090 �
PERMIT LSSUE DATE
0�'NER'S NAME: ,
RUTH & ARTHUR MANSON 12601 :_32 AVE NE
SANITARY NO. CONTROL NO.
�NE:
BUILDING PfiRMIT INFO
ARCHITECC/ENGiNEER: REMOVE ,'REPLACE GAS WATER e�oc ELECT PLUMH MECH
� 0 � 0
j p � LICENSED CONTRACTOR'S DECLARATION JOb DCSCrlpt101]
� v C I hMCby affirm that I am licenscd unJcr provisioos oC Chaptcr 9(commcncing
; y�� with Sccuon 7000) of Division 3 oC ihc Busincss and Prafcssiuns Codc. and my liccnte is
�� y in full force and e t
� v� Z Licenu 1 s — L�. � �
p Datc — — ContracWr
: F' � ARCHITECTS DECLARATiON
j a .�
a I undcrswnd my plans shali bc uscd as public rccords
)yU
� o y Liccnsed Pn�fcssional
y 3 OWNER-BUILDER DECLARATION
I hcrchy alTirm �hat I am excmpt Crom �hc Contractors Liccnsc Law for the
� p O following reason. (Scc6on 7031.5, Busincss and Profcssians Co�ic: My city or county
�,°, Pi which rcquires a pertnit to conswct, allcr, improvc, dcmolish, or �cpair any stn�cturc
prior u� ils issuancc, alsu rcquires thc applicant [or such pertnit to tIc a signcd sutcmcnt `, Valuation
_ Z } ,q. Ft. Floor Area
a �hat hc is IiccnscJ pucsuant lo t hc pmvisions o[ t h c C o n u a c t u r' s L i c� c n s c L a w ( C h a p t c r 9
Y t �(commencing wi�h Scction 7000) of Division 3 of ihc Busincss and Profcssions Codc) or
,'�, �� that he is exempt thracfrom and ihe basis [or the allcged exemption. My violation of Occupancy Type
Section 7031.3 by a�ry applicant for a permit subjecu the applicant to a civil penaity of APN Number
not more �han fivc hundred dollars (5500).
❑ I. u owncr oC tt�e pcoperry. or my cmployces with wages u the'v solc compentation.
w�ll do Ux work. and the swnuce is rrot intendcd or offered for salc (Sec. 7044. Business �2equired Inspections
and Ptofessions Cade: The Conuactor's Lianse Law docs not apply to an ownec of
propeny who huilds or improves Ihercon, and who does such work himsel[ or U�cou;d his
awn employces. provided chat such improvemenis are not intended or otCered f� sak. l[.
however, the building or improvement is sold within one ytar oC complction, ihe owner-
buildec will have �he burden of proving �hat he did not build or improvc tor pucpose u[
salcJ.
❑ I, as owna of �he properry, am exclusively conuuting wilh licensed contnctors W
constnut �he projett (Sec. 7044. Business and Professions Code:) lhe Conuaaors lr-
cense Caw dacs oot apply to an owner of propeny who builds or improves thercon. md .
who conuacts far such projects wi�h a conuactor(s) licensed pursuant to i6e Contractars
License Law.
Q 1 am ezempt under Sec . B& P C for this reawn
Owncr Da1e _ . -
WORKER'S COMPENSATION DECLARATION
1 hereby a[firm under penalry o[ perjury one of Ihe foltawing declarations
❑ i hsve and will mainuin a CeniGcate of Conaen� to self-insure [or Warlrets Campen-
satian, ss provided for by Sectian 3700 of the Labor Code, for Uu performance o( Uie
work for whicd this pertnit is issucd
❑ I havc and will maintain Workc�s CompensaUon Insurance, u �cquired by Scction ,
3700 0( �hc Labor Codc. Cor thc performancc of the work for which Utis pecmit ia isued.
My Workers m ensau 4 Insucancc c'er Policy nu are: /'�
Cartier. � liry No.: L/�n rG(.�J.l L---
CERTiFlCATE F EMPftON FROM WORKFRS'
COMPENSATION INSURANCE
(This section necd not be complcicd if the pertnit is for onc hundced dotlacs (5100) ,
oc Icss.)
I ceniCy that in thc perfortnance of ihc work fw which Ihis pertnit is issuc4 I sIw1I not
omploy any person ia any manncr so as w becomc subject io �he Worlccd Canpensatim �
Laws o( Califomia. Date
Applicant
N077CE TO APPLICAM: If, aftcr makin@ this CcniGcatc of Fxcmption, you shauW
bccome subjcct to the Worker's Compcntation provisions of iAc Lador Codc, you must
� z foMwiih comply with such provisions or this pecmit shall bc dccmcd mrokcd.
z O CONSfRUGTION LENDING AGENCY
(-�-i �-�. I hcfehy aRirm �hat there is a conswction knding agc�y for thc perfortnancc of
a� thc wurk Cur which ihis pecmit is iuucd (Scc. 3097. Civ. CJ ,
W Q Lendcr's Namc
j � (,cnda's Address
V � I certi(y ihat I havc «ad ihis application and siatc �hal thc above informaliun is
�� corrcct. I agree io comply wi�h all city and county oniinances and s�ate laws relating w
O� building conswction, and hcreby authori�e reprcscntativcs of this city to cntcr upon lAc
� W ahovc-mcnuoncd property (or inspccuon purjwses.
a (Wc) agree to save, indcm�i(y and kecp harmless the City of Cupertino against
�� liabilides, judgments, cos�s and expenscs which may in any way acccuc against said Gty
(� z in con:equence oC U�c granting of ihis permii. D8[e �
�--� APPLICANT UNDERSTANDS AND WILI. COMPLY WITH ALL NON-POINT Issued by.
SOUR A1'fONS. /
Re-roofs �
of Applicam/Convactor °"� T of R oof
HAZARDOUS MATERIALS DISCLOSURE YP
�11 �hc applicant or futurc building occupant storc or handlc hvardous matcrial
az defincd by thc Cupenino Municipal Cadc. Chaptcr 9.12. and the Hcal�h and SaCay
Cocle,Section25532(a)? All roofs �hall be inspected prior to any roofing material being installed.
❑ Ycs �o .
If a roof i� installed without first obtaining an inspection, I agree to remove
Will thc applicant or futurc building occupant usc cyuipmcnt or �iccs which
cmii harardous air con�aminan�s as dc6ncd by the Bay Arca Air Quality Managcmem all new m aterials for inspecrion.
as�c�?
� Ycs �Nu
I havc rcxl �he ha�ard<ws ma�crials requircmcn�t undcr Chaptcr6.95 of the Glifor-
nia Hcalth & Safcty Cadc. Secdons 25505.25533 and 25534. I undcrstand ihat iCthe bu�ld+oB
docs no� currcntly havc a tcnan� �ha[ it is my rcsponsiAiliry to noufy �hc occupant of �he
rcyuirc ch must bc mel prior to issuancc oC a Ccnifica�c of Occupancy. Signature of Applicant Date
'� All roof coverings to be Class "B" or better
or authorizcd agcnt Datc
From: 10/10/2007 07:50 �619 P.002J008
� / J U � � �v 381136
CITY OF C1:TPERT'Il�O
WATER I�EATER
CUPEI�TINO P'E1tNIiT A►PPLII�A'I'ION FURM �
�x # � �� (v� � ���, Q U n�: _ �� -� -�
Buildiag Address:
10245 EMPIRE AVE
own�s Name: Phone #
MANSON RUTH � ARTHUR 408 446-2505
Cantractor. phone #
fAST WATER HEATER COMPANY 800-454-8955.
CupF,rtino Business Lixagc � Stabe i.icense #
2910o snaes
Buiidiag Pc�mit Info:
Bld � h ��
7ob Descriptioa:
Remove/Replace C�as Water Heater
Residea ' g] Commcrcial ❑
Cost of Projeacct:
449.00 � .
Str�pped On P�rm Bonded
New Location � lacement �
Qhr• if
A licable Fet ID Fes Des ''on Fee C3rou
� PRWFiEATR Resi3�ntia1 Water Heat�er Nent BUII.DING
PCWHl3ATR Coamercial Water HeaterNent BUILDING
1 PP�RMTI'PEE Plunibing Permit Lssnaace PLUMBII�iG
1 TRAVDOC . Trav el �t Documeatation Pee BUILDINa
BUSLIC $usi aess Lioense BUII.IDNG
M
CITY OF CUPERTINO
�
4 ITEMS OF 12 PERMIZ RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN .. ....... 32622028.00
DATE ISSUED.......: 10/11/2007
RECEIPT #.........: BS000002962
REFERENCE ID # ...: 07100090
SITE ADDRESS .....: 10245 EMPIRE AVE
SUBDIVISION .......
CITY .............. CUFERTINO
IMPACT AREA .......
OWNER ............: RUZH & ARTHUR NIANSON
ADDRESS ..........: 10245 EMPIRE AVE
CITY/STATE/ZIP ...: CUFERTINO CA, 95014-1243
RECEIVED FROM ....: FWH ACQUISITION CO
CONTRACTOR .......: JEFF JORDAN LIC # 29100
COMPANY ..........: FAST WATER HEATER
ADDRESS ..........: 12601 132 AVE NE
CITY/STATE/ZIP ...: KIRKLAND, WA 98034
TELEPHONE ........: (800) 454-8955
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BSEISMICRE VALUATION 449.00 0.50 0.00 0.50 0.00
PPERMITFEE FLAT R.ATE 1.00 40.79 0.00 40.79 0.00
PRWHEATR LTNITS 1.00 24.48 0.00 24.48 0.00
TRAVDOC FLAT R.ATE 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