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09110092 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10525 PINEVILLE AVE CONTRACTOR:CUPERTINO PLUMBING PERMIT NO:09110092 OWNER'S NAME: ROUTH RICHARD R AND SHEILA P 1300 DELL AVE STE C DATE ISSUED: 11/17/2009 IER'S PHONE: 4082536047 CAMPBELL,CA 95008 PHONE NO:(408)253-0618 } LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG I— ELECT T_ PLUMB f— License Class Lic.# 62 � " MECH RESIDENTIAL COMMERCIAL Contractor 1 hereby affir that I am licensedunde�te ovisions of Chapter 9 JOB DESCRIPTION: WATER HEATER REPLACEMENT (commencing with Section 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: 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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$1000 1 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. APN Number:36913027.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Issued by y Date �`���- 9.18. / f Signature L_ Date,/- RE-ROOFS: RE-ROOFS: t_ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for 1 hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER constrict the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. 1 have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will pcmaintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the certify is issued. [ceertify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Ownerr author' a t: o Compensation laws of California. If,after making this certificate of exemption,I _ Dater—C become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save i-' -rnify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18• Licensed Professional Signature Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36913027 . 00 DATE ISSUED. . . . . . . : 11/17/2009 RECEIPT #. . . . . . . . . BS000009210 REFERENCE ID # . . . : 09110092 SITE ADDRESS . . . . . : 10525 PINEVILLE AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER ROUTH RICHARD R AND SHEILA P ADDRESS 10525 PINEVILLE AVE CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4528 RECEIVED FROM . . . . : CUPERTINO PLUMBING CONTRACTOR . . . . . . . : CARDIA, FRANK L LIC # 612 COMPANY CUPERTINO PLUMBING ADDRESS 1300 DELL AVE STE C CITY/STATE/ZIP . . . : CAMPBELL, CA 95008 TELEPHONE . . . . . . . . : (408) 253-0618 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 1, 000. 00 1 . 00 0 . 00 1. 00 0 .00 1BSEISMICR VALUATION 1, 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 #1394 --------------- TOTAL RECEIPT 110 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 518 WATER HEATER CITY OF CUPERTINO WATER HEATER ELI] PERMIT APPLICATION FORM CUPERTINO APN # 0(e ;)--I - Q)c) Date: Building Address: O r' ll ono Owner's Name: VPhone #: �CtrJ +- � A 12 Contractor: Phone #: Fax #: Cupertino 136iness License #: Contractor State License #: C� 2qq0e;- Contact: Phone #: Fax #: Building Permit Info: Bldg ❑ Elect ❑ Plumb Mech ❑ Residential � Commercial ❑ Solar F-1Ifsolar, number of kilowatts: Strapped �h Platform Bonded E] --mew Location ❑ Replacement Valuation (cost of project): /© jam Project Size: Express A�andard ❑ 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 08/20/09 CITY OF CUPERTINO WATER HEATER PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Permit Type Group 1PCWHEATR Commercial Water B PCWHEATR HeaterNent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICOM Seismic Commercial B 1 PRWHEATR Residential Water B PRWHEATR HeaterNent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICRE Seismic Residential B 1 PPERMITFEE Plumbing Permit P 1 TRAVDOC Travel & B Documentation 1 BUSLIC Business License B . n oor Atr ua ity an Fmt-shes INPUT Rescu-ces Energy 1AD"Health 1.Use LowMaVOC Paint 1 IAQ/Health pts y=yes 0 2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0 3.Use Low/No VOC Adhesives 3 IAQ/Health pts y=yes 0 4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0 5.Use Engineered Sheet Goods with no added Urea Formaldehyde 61AQ/Health pts y=yes p 0 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 7.Seal all Exposed Particleboard or MDf 4 IAQ/Health pts y=yes 0 8.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0 9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y--yes 0 10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 0 1 1 1 N.Flooring 1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0 2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 0 3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0 4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 0 5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0 6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0 1 1 1 Total Points Available: t 1401 1301 57 Total Points Project 1 01 0 0 pro idi gguideline re 'el�rSrSgreenpointsnna12.12.D4protected.xls Community Development xk171. 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 XPEI�TINO Building Department JOB ADDRESS: PERMIT # /D 5-�2.5- !2'h e✓ le- case ev ,�, .,c) Dc1 L 1 O oQ OWNER'S NAME: ; k, I VR-\, PHONE # ,2-s- 6D y GENERAL CONTRACTOR: Cu Q r %Vlo P1ujv7bj'(nj FAX # I am not using any subcontractors: 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 C v e ,,,o m&-Vit aozqq6�- Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date