14100043CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21884 WOODBURY DR CONTRACTOR: AAA FURNACE & AIR PERMIT NO: 14100043
CONDITIONING
OWNER'S NAME: MARILYN BECK 1712 STONE AVE DATE ISSUED: 10/07/2014
OWNER'S PHONE: 4087182284 SAN JOSE, CA 95125 PHONE NO: (408)293-4717
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL
REMOVE AND REPLACE 50 GAL WATER HEATER
License Class �} Lic. # I
Contractor A 4 v CfV A C Date L
I hereby affirm that I am licensed under the provisions of Chatter 9
(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:
I 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: $1693
have and will maintain Worker's Compensation Insurance, as provided for by
on 3700 of the Labor Code, for the performance of the work for which this APN Number: 32619067 00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating WITy PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter 180 DA F
`�
upon the above mentioned property for inspection purposes. (We) agree to save ' RO ALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments, 1 O /_7
costs, and expenses which may accrue against said City in consequence of the Issued by: Date: 1
granting of this permit. Additionally, the applicant understands and will comply
with all ource regulat' n per the Cupertino Municipal Code, Section
9.
RE -ROOFS:
JSignature 4 ate () 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
inspection.
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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 & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain complian upertino M nicipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Saf ode, Sections 505 5 , and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: WW
Date:
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional
9 18.
Signature Date
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CITY OF CUPERTINO
1RIPIPi. F.CTTMATnR — RITII.DING DIVISION
ADDRESS: 21884 WOODBURY AVE
DATE: 10/07/2014
REVIEWED BY: MENDEZ
APN:
BP#:
"VALUATION: 1$1,693
PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE: p
PENTAMATION PRWHEATR
PERMIT TYPE: i
WORK
REMOVE AND REPLACE 50 GAL WATER HEATER
SCOPE
(Plan
APPLIANCE / EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Heater 1PRWHEATR 1 # $29
TOTALS: $29.00
._
.ko) 1" rxn Plumb. Plan Check L0.0 hrs $0.00 1 iev_ P w�l C:hee/,,
doh I' }malt Fee: Plumb. Permit Fee: IPPERMIT
7n Other Plumb Insp. E-hrs�$4 r),17ef t
retial. l aSj_,t iFee: 11honh. hasVJ.
NOTE: This estimate does not include fees due to other Departments (Le. Ytannang, ruaac worKs, rare, aanitary Sewer "tstrtcy acavuc
_ _ X- -- --- G,.--.1 ., IL .... ..t;....;.....«..:uf ,. ..f:n s... n:lnxaa —.4 n o ..I,, nn octimnto Ca"tart tho vont For addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/13)
FEE
QTY/FEE
MISC ITEMS
Plan ( C/ae '
'tt;all. PC 14,ec
PME Check:
$0.00
(Plan
PME Unit Fee:
$29.00
PME Permit Fee:
$48.00
C ons0 ,wtz 017
Administrative Fee: 1ADMIN
$45.00
Work Without Permit? ® Yes 0 No
$0.00
�f c r'i`a rx �<`e't% T`lL tr't t7trl� Feeb':
Travel Documentation Fee: ITRAVDOC
$48.00
Strony Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
a
. �.
$171.50
$0.00 TOTAL FEE:
$171.50
Revised: 08/20/2014
,44 t�-t i +v c , CF. 1, AZT
Pa e4of5
Prescrl ,time Certificate .of•C m Bance; Residential # of Stories
r)imate Zone it
}3Es3i1ential A4terahons
Pro}ect�lame:
Y _
Configuration
HVAC SYST i45 - HtATING Du:C.t at='P�ipi�ng (Central, Split,
Nlinimum Insulation Thermostat
Efficiency Distribution T e S ace, Packa c or H dronic)
Heating'squipment R -Value
T e and Ca aci
i•7,7 (�PLIE or HSPF T e and Location)
tal
m onenr Package C, or except where electric hearing is supplem �Sr� Ib(+jeecc for o �apaciry
!. lndicaie Healing Type (Cenr,.al Furnace, ,yynlCournace, Near pump, Eviler• Electric Resistance, etc.)
1: Electric resistance hearfng is allowed only p a rime•l'imiling device not exceeding 30 minutes). See 3+cable boxes.
2 KW or 7,000 Bru/hr electric hearing is controlled by
j Refer
to the HERS Verification section on Page 4 of the CF,
e Form for additional reytr++'emenls and check app
4, lndicaie Type or Location (Ducts, Hydropic in Floor, Radiators.
HVAC SYSTEMS - COOLING Configuration
Minimum Duct or Piping (Central, Split,
Efficiency Insulation InsuThermostat dronic
SE,Distribution T e S ace, Packa a or H
Cooling Egtiipment (ER/EER or T e and Location R -Value
T e and Ca acit �Op)
11
1. Indicate Cooling Tvpe (ASC. Hear pump 'Evap: Cooling, e(c)
2. Refer to rhe KERS Verification section . Page 4 of rhe CF,Rjerc,Form for additional requirements and check applicable boxes -
Heat
), Indicate T e or Location (Ducts, H dronic in Floor, Radiators,
FE.ATIN.G
dronic space hearing. Individual dwelling DHg' heaters must +
allons. Hot r water pipe insulation from the DH hearer to the kirchen(s) and on all undergroun
List ware,• hearers and boilers jot borh'dome.r.tic hot water (DKW) heaters and by
gas or propane fired, and may nor exceed SO g External Tani
es is re uired in all com. onen(acka es m all climate zones. Ener Factor or Insulation'
Number In Tank g R.Values
Type/Fuel Distribution Type Ca aci al) Thermal Efficient
Water Heater Typ S stem
T ei (Standard, Recirculatin )i
S CL
1. Indicate Type (Storage Gar, Heat Pump, lnsrarltaneous• etc.)
150(n). The Prescriptive requireflw"I d
?. Reci+•ctrlalfng systems serving lawe
e"iiater hlear ngts lsyseem Jor single dwellinget [he recirculation qun+rrsmenrs oj§
not allow the installation of a recirculating
3. The external water hearin. tank. and i es shall be insulated to meet the re uiremenrro 150 f ecial Features spec f
i ted in this checklist blow•
The enforcement agency should pay special attention to the Sp
SPEirTAL F`A T tJKES
These items maw re wire written 'usti [ cation and documentation ands eclat verification-
.
NEW.ROiSF A'SSIYLY •Radiant Barrier
• The radiant barrier re.. t)iremant of 1 S l ( 2 docs nota ' y to roof alterations.
Slab l dg'e (Perimeter) Irtstriatilon Q YES Q NO
YES, In Climate*Zone 16 in Component Packages D, R 7 insulation is required.
Heated Slab Insulation CJ YTJS M NO
insulation re uire.d.for all. heated.slabs, in ail Climate Zones. See details in Table l I $ A o re wired under com orient Pa
YES: Slab ed e n R 4 is
Raised Slab Insuaation U YES Q NO R:g insulation is.re: wired; in Climate. Zones 1.2& 15,.
YES: In.Cfirnate Zones I, 2; I.IA & 16, [oath. .
Thermal IVtass
To obtain Co mrtr [[.ante Credit .for the installation of the .. 'al mass; :u"se.the:Esrfa�ance A ..
HERS Provider:
Registration 001e/1•ime:
Registration Number:
2008 Residential Compliance Forms
2
f Building Department
City Of Cupertino
�,► r 10300 Torre Avenue
Cupertino, CA 95014-3255
�s rzn
s Telephone: 408-777-3228
CUPERTINO�� Fax:408-777-3333
c t"'1TRA�CTOR/SUBCONTRACTOR LIST
*Our municipal code re i es all52b-usi iesies wort g in'the city -to have a City of Cupertino business license.
NO .BUILDING FIN_rMvcaCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
x
GENERAL CONTRACT.AND�I.L SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE,
I am not using :any subcot�%actors
;Signature Da e
Please check apphcabl ,�.' o tors�and complete the following information:
. .
V SUBCONTRACTOR , BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork A.
Cement Finishing
Electrical
Excavation
Fencing
Flooring/ Carpeting '
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
A
Masonry
Painting / Wallpaper N r
Paving
Plastering -� _
Plumbing °F
Roofingf-
''v i .ger ti
Septic Tank,g
_XYC k if `
Sheet Metal
Sheet Rock
Tile r
Owner /.,"ion arSgnature ,. Date
z �y
t a,
JOB ADDRESS:
PERMIT # Y U Z
OWNER'S NAME
PHO #
GENERAL CONTRACT s•,
• 4t Ca= LJKS.
BUSINESS LICENSE # 10 671
ADDRESS: 144,Z a
ctt is-�.
�j3Z CITY/ZIPCODE:�"3. �5�� CA qSi 3Z--
*Our municipal code re i es all52b-usi iesies wort g in'the city -to have a City of Cupertino business license.
NO .BUILDING FIN_rMvcaCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
x
GENERAL CONTRACT.AND�I.L SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE,
I am not using :any subcot�%actors
;Signature Da e
Please check apphcabl ,�.' o tors�and complete the following information:
. .
V SUBCONTRACTOR , BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork A.
Cement Finishing
Electrical
Excavation
Fencing
Flooring/ Carpeting '
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
A
Masonry
Painting / Wallpaper N r
Paving
Plastering -� _
Plumbing °F
Roofingf-
''v i .ger ti
Septic Tank,g
_XYC k if `
Sheet Metal
Sheet Rock
Tile r
Owner /.,"ion arSgnature ,. Date
z �y
t a,
SMOKE / CARSON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(aDcupertino.ora
WwJ6 r, Dn C,
Permit No. 1 y 1000 L4'3
[tTIFICATE '
[BION,; Y
This affidavit is a self -certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2013 CRC Section R314, 2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for
inspections are required.
GENERAL INFORMATION
Existing single-family and multi -family dwellings shall be provided with Smoke Alarms and Carbon
Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds
$1000.00, CRC Section R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon
Monoxide Alarms be installed in the following locations:
AREA
SMOKE ALARM
CO ALARM
Outside of each separate sleeping area in the immediate vicinity of the
bedroom(s)
X
X
On every level of a dwelling unit including basements
X
X
Within each sleeping room
X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel -burning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated.
In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do
not result in the removal of wall and ceiling finishes or there is no access by means of attic, basement or crawl
space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for
alarms which must be connected to the building wiring.
As owner of the above -referenced property, I hereby certify that the alarm(s) referenced above has/have been
installed in accordance with the manufacturer's instructions and in compliance with the California Building
and California Residential Codes. The alarms have been tested and are operational, as of the date signed
below.
1 have read and agree to comply with the terms and conditions of this statement
Owner (or Owner Agent's) Name:
ct
/`�a�............. ........!....... Date:
....... ...�J....i
Contractor Name:
Signature................................................................... Licl...................................... Date: ...................
Smoke and CO form.doc revised 03/18114