12110148 CITY OF CUPERTINO BUILDING PERMIT
BOILDINGADDRF-SS: 7595 ERIN WAY CONTRACTOR: PAYLESS WATER PERMITNO: 12110148
HEATERS
OWNER'S NAME: ALISIIETTIE BlIOOMAIAII 24895 AVENUE.ROCKEFELLER DATE ISSUED: 112812012
OWNER'S PHONE: 4082530713 VALENCIA,CA 91355 MILNE NO:(661)775-2944
0 LICENSED CON'TRACTOR'S DECLARATION .1011 DESCRIPTION: RF-SIDENMAL 1i COMMERCIAL
11
License Class C 3lo Lic.0 g36o91(p REPLACE 40 GAL WATER HEATER IN SAME LOCATION
Contractor Date It-ye-12,
1 hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business S 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.FI Floor Area: Valu:Rion:$1000
I have and will maintain p'orker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
APS Number:35920014.00 Occupancy'1)pr.
permit is issued.
APPI.ICA,N1'CER'IIFICAI'ION
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 mod state laws relating WITHIN 180 DAY F PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY M LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, II ( j�
casts,and expenses which may acerae against said City in consequence of the �_ ?�
granting of this permit. Additionally,the applicant understands and will comply Issued by; Dale:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
II'�p',L RF:ROOFS:
Signature /'-0 W'�z Date D All roofs shall be inspected prior to mmy roofing material being installed, If a roof is
installed without first obmining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-RUILDF.R DECLARATION
Signature of Applicant: Date:
hcrebr affirm that I am exempt from the Contractor's License Law fur one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BE:HTR
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(Sce.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to 11AZARDOUS NIATERIALS DISCI.OSURF
construct the project(Sce.7044,Business S Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth S Safetv Code.Sections 25505.25533,and 2553.1. twill
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Ilealth S Safety Code,Section 25532(x)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 Ray Area Air Quality Management District 1
performance of the work for which this permit is issued, wi11 maintain compliance with the Cupertino Nlu nicipai Code,Chapter 9.12 and
1 have and will maintain p'orker's Compensation Insurance,as provided for by the Ilealth S Safety CodcIS ection 25505.25533.and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized igen . Ualc
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
Compensation laws of California. If,after making this certificate of exemption,I CONSTRIICI'ION LENDING AGENCY
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
IortMyith 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
AI'PI.ICAN'I'CER'I'IFICA'I'ION Lender's Address
1 certify that 1 have read this application and stale 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
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 5 ARC111TECI"S DECLARATION
costs,and expenses which may accrue against said City in consequence of the I understand my phos 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,Sectimm Licensed Professional
9.18.
Signature Date
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB.ADDRESS: 15q5 I V1 PERMIT#
OWNER'S NAME: AIIShe++'t JSh0Oocjj A t- PHONE # LIO`d S 3-0713
GENERAL CONTRACTOR: ULS 0. lSl BUSINESS LICENSE #
ADDRESS: $ LL CITY/ZIPCODE: O.LQ C,,-k 913SS
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL .OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
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•hCarpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Shect'Metal
Sheet Rock
Tile
N0�.,,Q, r I - z-7 - (z
Owner/Contractor Signature Date
Prescriptive Certificate of Compliance: Residential WATER HEATER CF-IR-ALT-Water Heater
Date Enforcement Agency: Climate Zone# # of Stories Permit #
I�-2�-1 z 12
Site Address: I'1
7s9s 'rtr� W
Building Type t Sin le Family ❑ Multi Family
NOTE. Thisform is not to be used or New Constructed Buildings or Additions
WATER HEATLNG
List water heaters and boilersfor both domestic hot water(DHW) heaters and hydronic space heating.
Individual dwelling DHW heaters must be gas or propane fired, and may not exceed SO gallons. Hot water pipe
insulation from the DHW heater to the kitchen(s) and on all underground hot water pipes is required in all
component packages in all climate zones.
Water Heater Type/ Distribution Type Number Tank Energy Factor External
Fuel Type' (Standard, in System Capacity or Tank
Recirculating)2 (gal) Thermal Insulation
EfflIi__ciencR-Value3
0.� S rJ-iCiLL({(y t W
1. Indicate type(Storage Gas, Heat Pump, Instantaneous, etc)
2. Recirculating systems serving multiple dwelling units shall meet the recirculation requirements of
§150(n). The Prescriptive requirements do not allow installation of a recirculating water heating system
for single dwelling units.
3. The external water heating tanks and pipes shall be insulated to meet the requirements o ISO ' .
Declaration Statement
• 1 certify under penalty of perjury,under the laws of the State of California,the information provided on this form is accurate
and complete.
a 1 certify that the energy features and performance specifications identified on this Certificate of Compliance conform to the
requirements of Title 24,Parts I and 6 of the California Code of Regulations.
Name: Signature:
VU.Q.t:lft-� MCI k- s
Company- > � Date:
Paq Lo-es Ldo: Lr kJ—Ttom
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Address: License:
aysgs Ruelnue- (33to1;�t(0
City/State/Zip: Phone:
u(lt"LL14 �� Q13Ss �(c1 7-7s -29 1 (
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For assistance or questions regarding the Energy Standards, contact the Energy Hotline at 1-800-772-3300.
CF-IR-ALT;5/17/10 Page 1 of I
GENERAL PERMIT APPLICATION M E r
_ COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 1�
10300 TORRE AVENUE-CUPERTINO,CA a�a i=-?2zizi ��✓`
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&EPMscAFp-2011.doc reused 06/71/.11
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: 'VALUATION: $1,000
'PERMITTYPE: Plumbing Permit =PLAN CIiECK'1'1'PE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION PRWHEATR
USE: PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Heater 1PRWHEATR 1 # $27
TOTALS: $27.00
Mech. Plan Check Plumb. Plan Check 0.0 hrs $0.00 Flea PI...Check
Mech.Permit Fee: Plumb. Permit Fee: IPPERMIT Elec. Permit Fee:
Other,t/ech.Insp. Other Plumb Insp. 0.0 hrs L$45.00 Other Elcc.hasp.
,Mech.Insp.Fee: Phnuh. htcp.Fee: Mer. 1nsp. Fee.-
NOTE:
ee:NOTE: This estimate roes not include jeev roe to other Departments(i.e. Planning, Public Works. Fire.Sanitary Sewer District,School
District,etc.). Thesefees are based on the prelintinan information arailahle and are only an estinune. Contact lite Dept for atho'I info.
FEE ITEMS (Fee Resohaion 11-053 EfX 711112) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
SuppL Insp Fee
PME Unit Fee: $27.00
PME Permit Fee: $45.00
Construction Tax:
Administrative Fee: IADMIN $42.00
Work Without Permit? O Yes (F) No $0.00
Advanced Planning Fees:
Travel Documentation Fee: 1TRAVDOC $45.00 A
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $160.50 $0.00 TOTAL FEE: $160.50
Revised: 10/01/2012