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09090094 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDIKESc: 22042 HIBISCUS DR CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO:09090094 DATE ISSUED:09/14/2009 OWNER'S NAME: JIM LEONARD 'ER'S PHONE: 4087392986 PHONE NO: p LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT f— PLUMB License Class Lic.# MECH r— RESIDENTIAL T_ COMMERCIAL Contractor Date JOB DESCRIPTION:INSTALL TANKLESS WATER HEATER IN NEW I hereby affirm that I am licensed under the provisions of Chapter 9 LOCATION ON (commencing with Section 7000)of Division 3 of the Business&Professions OUTSIDE WALL;CONTRACTOR(PLUMBING PRO)PD FOR BUS Code and that my license is in full force and effect. LIC 9/14/9 1 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. 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 Sq.Ft Floor Area: Valuation:$3200 permit is issued. APPLICANT CERTIFICATION APN Number:32602034.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Issued�by 7-�" G�..''�c�`__ Date: �7' Signature Date OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for 1,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Mu icipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safety de,Sec' s 25505,2553 ,and 25534. 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 O or ut o �( forthwith comply with such provisions or this permit shall be deemed revoked. ate: (J APPLICANT CERTIFICATION CONSTRTION LENDING AGENCY I certify that I have read this application and state that the above information is ima that there is a co4trnction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save i-'-mnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address and expenses which may accrue against said City in consequence of the g:..i,.,ng of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all;non-point:;rce re ti r the Cupertino unicipal Code,Section 9.18. 1 understand my plans shall be used as public records. Date~ Licensed Professional CITY OF CUPERTINO PERMIT RECEIPT OPERATOR: patg 6 ITEMS OF 6 COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 32602034 . 00 DATE ISSUED. . . . . . . : 09/14/2009 RECEIPT #. . . . . . . . . BS000008673 REFERENCE ID # 09090094 SITE ADDRESS 22042 HIBISCUS DR SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER JIM LEONARD ADDRESS 22042 HIBISCUS DR CITY/STATE/ZIP CUPERTINO, CA 95014 RECEIVED FROM JAMES A LEONARD CONTRACTOR TBD - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC- --NEW-BAL- ---------- ---------- ---------- ------ 00 --- --------- 1 . 00------------- 1 . 00 0 . 1BCBSC VALUATION 3, 200 . 00 0 .50 0 .00 0 . 50 0 . 00 1BSEISMICR VALUATION 3, 200. 00 1BUSLIC FLAT RATE 1 . 00 114 . 00 0 . 00 114 . 00 0 . 00 1. 00 42 . 00 0 . 00 42 . 00 0 .00 1PPERMITFE FLAT RATE 1PRWHEATR UNITS 1. 00 25 .00 0 .00 25. 00 0 . 0 1TRAVDOC FLAT RATE 1. 00 42 . 00 0. 00 42 . 0 .00 -- TOTAL PERMIT 224 .50 0 .00 224 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ------------ --------------- -- CREDIT CARD 224 .50 VISA --------------- TOTAL RECEIPT 224 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION ---------------------------- -------- ------------------ 518 WATER HEATER CITY OF CUPERTINO WATER HEATER PERMIT APPLICATION FORM CUPERTINO APN #3 Date: o� �� civ Building Address: Owner's Name: Phone #: Contractor: Phone #: Fax #: �22— Cupertino Business License #: Contractor State Lic nse #: Contact: �..� � Phone #: Fax #: Building Permit Info: Bldg [ Elect Plumbig Mech E�---- Residential Commercial ❑ Solar ❑ If solar, number of kilowatts: Strapped ❑ On Platform ❑ Bonded ❑ New Location Replacement ❑ Valuation (cost of project): �� `stie v t-g d ( 9\ Project Size: Express Standard ❑ 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: V 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 C / 1 PPERMITFEE Plumbing Permit P 1 TRAVDOC Travel & B Documentation 1 1 BUSLIC Business License B M. ndoor Air ua ity and Finishes 0 1 UseLow/No-VOC Paint 1 IAQ/Health pts y=yes 21AQ/Health is es 0 2.Use Low VOC,Water-Based Wood Finishes P Y=y 0 3,Use Low/NoVOCAdhesives 3 IAQ/Health pts y=yes 3 Resource is es 0 4.Use Salvaged Materials for Interior Finishes P Y=Y 5.Use Engineered Sheet Goods with no added Urea 6 IAQ/Health is es 0 Formaldehyde p y-y 0 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes7. 0 Seal all Particleboard or MDF 4 IAQ/Health.pts y=yes 0 B,Use FSC Certified Materials for Interior Finish 4 Resource pts Y=Y8S 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 { 1 ! N.Flooring B Resource is Y=Yes 0 1.Select FSC Certified Wood Flooring p y-y 0 2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 4 Resource is Y=Yes 0 3.Use Recycled Content Ceramic Tiles p Y-y 0 4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 4 Resource is Y=Yes 0 5.Use Exposed Concrete as Finished Floor P Y-y 0 6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes Total Points Available: 140f- 130 a p Total Points Project Received: 0 0 G:data/progstgreenbuildngguidelines/remodelers/gr np6intsfina12.12.D4pro1ected.x1s Community Development 10300 Torre Avenue ex Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 -,UPEkTINO Buildin De artment JJOVBj ADDRESS: PERMIT # oq o n oo q / OWNER'S N PHONE # GENERAL CONTRACTFAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the followormation: 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 Roofing Septic Tank Sheet Metal Sheet Rock Tile j 01 Owner/Contractor Signature D