13030020 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21979 SAN FERNANDO AVE CONTRACTOR:CITY OF CUPERTINO PERMIT NO:13030020
OWNER'S NAME: CITY OF CUPERTINO 21979 SAN FERNANDO AVE DATE ISSUED:03/05/2013
OWNER'S PHONE: 4087773200 CUPERTINO,CA 95014-2823 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL U COMMERCIAL
License Class Lic.# BLACKBERRY FARM-REMOVE AND REPLACE WATER
HEATER
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 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:$500
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 APN Number:35710008.00 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 WITHIN 180 DAYS OF 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 r R M LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date 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
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,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. I will
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: Health&Safety Code,Section 25532(a)should 1 store or handle hazardous
1 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 compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534. .
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent: Dater
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall Lf
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. It after making this certificate of exemption,I CONSTRUCTION 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
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 .S
GENERAL PERMIT APPLICATION �0 c)� p
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
.10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 � '
CUPERTINO (408)777-3228• FAX(408)777-3333• building(a?CUDertino.org
SC
PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJfiC[ADDRESS Q0 APN
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OWNER NAME PHONE E-MA
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STREET ADDRESS STATE,ZB FAX
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CONTACT NAME P ONE E-MAIL
STREET ADDRESS CrTY,STATE,ZIP FAX
❑ OwNER ❑ OWNER-BunimER ❑ OwNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSENUMEER LICENSETYPE BUS.LIClt
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGNEER NAME LICENSE NUMBER BUS.LC N
COMPANY NAME E-MAIL FAX
STREETADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFDor DUPLEX ❑ MUI.TT-FA y PROJECTINWBDLAND ❑ YES PROJECT IN ❑YES ISTHEBLDGAN ❑YFS
BUILDING: ❑COMN.EACW, URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EJCYIERHOMEP ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION: RECEIVED BY:
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the opowner's behalf. I have read this
application and the information I have provided is correct I have read the Description of Work and verify it is accurate. agree to comply with all applicable local
ordinances and state laws relating to b ilding construction. I authorize representatives of CUpudno to enter the above-iden ified propettyy for inspection pu@oses.
Signature of Applicant/Agent: Date: 3f SX- efK3
SUPPLEMEWALINFORMATIONREQUMED OFF19E,1JSfO%LY
OYER-THE-COUNTER
❑ EXPRESS
U
n ❑ STANDARD
U
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❑ hwop
MEPAAIscApp_2011.doc revised 06/21/11
INSTALLATION CERTIFICATE CF-6R-MECH-01
Domestic Hot Water (Page 1 of 2
Site Address: Enforcement Agency: Permit Number.
54A/ 4oa L4=AznV'9
1. WATER HEATING SYSTEMS:
Distribution Rated
CEC Type If #of Input(kW Tank Standby
Heater Certified Mfr.Name&Model (Std,Point-of- Recirculation, Identical or Volume Efficiency Loss
Type Number Use etc) Control Type System Btu/hr)' (gallons) (EF,RE)i (°/n)t
645 33F 0a) 30 O,6Z. AV
Note 1:For small gas storage(rated input less than or equal to 75,000 Btulhr),electric resistance and heat pump water heaters,list
Energy Factor(EF).For large gas storage water heaters(rated input ofgreater than 75,000 Btwhr),list Recovery Efficiency(RE),
Thermal Efficiency,Standby Loss and Ratedlnput. For instantaneous gas water heaters,list the Thermal Efficiency and Rated Input.
2. Mandatory Measures
TO COMPLY-ALL BOXES MUST BE CHECKED
❑ §110-§113:Water heaters,showerhead and faucets are certified by the California Energy Commission.
§1500):Water System Pipe and Tank Insulation.And Cooling Line Insulation
1. Storage tank insulation
❑ A.Storage gas water heaters rated with an Energy Factor no greater than the federal minimal standard are
externally wrapped with insulation having an installed thermal resistance of R-12 or greater;and
❑ B.Unfired storage tanks or other indirect hot water tanks have R-12 external insulation or R-16 intemal
insulation where the internal insulation R-value is indicated on the exterior of the tank.
2. Water piping and cooling system line insulation thickness and conductivity
❑ First 5 feet of hot and cold water pipes closest to water heater tank,non-recirculating systems,and entire
length of recirculating sections of hot water pipes are insulated per Standards Table 150-B;and
❑ Pipe insulation for steam hydronic heating systems or hot water systems>15 psi,meets the requirements of
Standards Table 123-A.
❑ Insulation is protected from damage,including that due to sunlight,moisture,equipment maintenance,and
wind.
❑ §151(£)81):If indicated on the CF-1R,all hot water piping that runs from the hot water source to the kitchen fixtures is
insulated per Standards Table 150-B.
2008 Residential Compliance Forms August 2009
INSTALLATION CERTIFICATE CF-6R-MECH-01
Dome'sik Hot Water_ (Page 2 of 2
Site Addressi . Enforcement Agency: - Permit Number:
3. Central Water Heating in Buildings with Multiple Dwelling Units(required for prescriptive)
TO COMPLY-ALL BOXES MUST BE CHECKED
❑; All hot water,piping in main circulating loop is insulated to requirements of§1500)
❑ Central hot water systems serving six or fewer dwelling units which have(1)less than 25' of distribution piping
outdoors;(2)zero distribution piping underground;(3)no recirculation pump;and(4)insulation on distribution
piping that meets the requirements of Section 1500)
❑ Central hot water systems serving more than 6 dwelling units-presence of either a time control or a
time/temperature control
DECLARATION STATEMENT
• I certify under penalty of perjury,under the laws of the State of California,the information provided on this form is true and correct
• I am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction,or an authorized
representative of the person responsible for construction(responsible person).
• I certify that the installed features,materials,components,or manufactured devices identified on this.certificate(the installation)
conforms to all applicable codes and regulations,and the installation is consistent with the plans and specifications approved by the
enforcement agency.
• I reviewed a copy of the Certificate of Compliance(CF-1R)fom approved by the.enforcement agency that identifies the specific
requirements for the installation. I certify that the requirements detailed on the CF-f R that apply to the installation have been met.
• I will ensure that a completed,signed copy of this Installation Certificate shall be posted,or made available with the building
permit(s)issued for the building,and made available to the enforcement agency for all applicable inspections. I understand
that a sigged_copy of this Installation:Certificate:is required to be included with the documentation the builder provides to
the building owner at occupancy.
Company Name: (Installing Subcontractor or General Contractor or Builder/Owner)
of c4Q5Zmn,
Responsible Perso I Marne:' Respo ible Person's Signature:
FAA
CSLB Lice Date Signed: Position With Company(Title):
2008 Residential Compliance Forms August 2009