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09010030 CITY OF CUPERTINO BUILDING DIVISIONpE�yjjT1 ,�Q '�Ik :. BUILDING ADDRESS: PERMIT NO. 10633 M ALL LLEY OWNER'S NAME: PERMIT ISSUE DATE v 40 SAN CONTROL NO. ARCHITECTIENGINEER: BUILDING PERMrr INFO BLDG ELECT PLUMB MECH WATER HEATER REPLCMNT Q Q Q Q O p LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description with Section 7000)of Division 3 of the Business and Professiornsgodc,and my license is in full force and effect. X177��f�jj'"'!! 61 ' 2License C Lie.k F p Datc T/N� Contractor LL *t lab "1 ARCHITECT'S DECLARATION 1 understand my plans shall be used as public records �yU yC in Licensed Professional n y 3 OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractors License law for the LOO following reason.(Section 7031.5,Business and Professions Code:Any city or county K$V which requires a permit to construct,alter,improve,demolish,or repair any structure y prior to its issuance,also requires the applicant for such permit to file a signed statement F= that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation (commencing with Section 7000)of Division 3 of the Business and Professions Code)or y that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a cavil penalty of APN Number Occupancy Type not more than five hundred dollars(5500). ❑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 sae(Sec.7044,Business Required Inspections and Professions Code:The Contractors License Law does not apply to an owner of q P property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale.If, however,the building or improvement is sold within one year of completion,the owner. builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractors U. cense law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractors License Law. ❑1 am exempt under Sec B&P C for this reason OwnerDate WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: 1 have and will maintain a Certificate of Consent to self-insure for Workers Compen- on,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 required by Section 3700 of the labor Code,for the performance of the work for which this permit is issued My Worker's Compensation Insurance carrier anDlicy number are: Carrier�lQ/r^^ STAT, 10`t,ol'ucyNo.: &A It 3 -' CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section treed not be completed if the permit is for one hundred dollars($100) or less) 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 Workers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must ,J O forthwith comply with such provisions or this permit shall be deemed revoked. Z"" CONSTRUCTION LENDING AGENCY I hereby affirm dial then;is a construction lending agency for the performance of the work for which this permit is issued(Sec.3097,Civ.C.) WR, 0 Lenders Name a z Lenders Address U 0 T certify that 1 have read this application and state that the above information is LL.P correct.I agree to comply with all city and county ordinances and state laws relating to 0 U building construction,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against r�r IDA liabilities,judgments,costs and expenses which may in any way accrue against said City V Z in consequence of the granting of this permit. _ (" r"r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date Gam" SOU cg RE ULATIONS. /. �-- A�5 t.L691 r� Re-roofs _ Signature of of AA;plicae o tractor Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely Code,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes bm Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. trice? ❑Yes M>5�. I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if Ute building does not currently have a tenant,that it is my responsibility to notify the occupant of the reyuirem n whit must be met prior issuance of a Certificate of Ocff u Signature of Applicant Date _ /z feet All roof coverings to be Class" ''or better Owner or authorized agent Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . . 37534010 . 00 DATE ISSUED. . . . . . . : 01/08/2009 RECEIPT #. . . . . . . . . : BS000006928 REFERENCE ID # . . . : 09010030 SITE ADDRESS . . . . . : 10633 MORENGO DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . . AMELIA MANZANO ADDRESS . . . . . . . . . . . 10633 MORENGO DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : ALL VALLEY PLUMBING CONTRACTOR . . . . . . . : MARY SANDBRINK LIC # 23015 COMPANY . . . . . . . . . . : ALL VALLEY PLUMBING ADDRESS . . . . . . . . . . : 3345 SELDON CT CITY/STATE/ZIP . . . : FREMONT, CA 94539 TELEPHONE . . . . . . . . : (510) 376-4816 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 700 . 00 1. 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 700 . 00 0 . 50 0 . 00 0 . 50 0 . 00 1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 .79 0 . 00 1PRWHEATR UNITS 1 . 00 24 .48 0 . 00 24 . 48 0 . 00 1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 107 . 56 0 . 00 107 . 56 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 107 . 56 #1877 --------------- TOTAL RECEIPT 107 . 56 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 518 WATER HEATER CITY OF CUPERTINO 09 01 C)C) - W .TER HEATER Cl OF PERMIT APPLICATION FORM TllN0 C, P Date, -:2 I d ing *- Uress: A -ax I'S iL -erTino Phone ,or itaci, aK Fk! d LT r�t) E I hz�Xjl C "u-94( il, ent Z,-Bonded -oca 00 u a!, ------ ation- ynust be cornpleted and attached t o this applic Green Building Ch.ec Groep. Building Points achleved* CITY OF CUPERTINO OWATER HEATER -'JPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Permit Type Group 1PCWHEATR Commercial Water B PCWHEATR HeaterNent 1BSEISMICOM Seismic Commercial B 1 PRWHEATR Residential Water B PRWHEATR HeaterNent r 1BSEISMICRE Seismic Residential B f 1 PPERMITFEE Plumbing Permit P / 1 TRAVDOC Travel & B Documentation 1 BUSLIC Business License B M.Indoor Air ua rty and Frntshes INPUT Resourres Energy IAQ/'Health 1.Use Low/No-VOC 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 0 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0 7.Seal all Exposed Particleboard or MDF 4 IAQ/Health. pts y=yes 0 B.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 ! N.Flooring 1 1 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 J 6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 1 1 1 Total Points Available: 1 1401 130 57 Total Points Project Received: 01 01 0 G:data/progs/greenbuildingguidelines/remodelers/greenpointsfinal2.12.D4protected.xls Community Development 10300 Torre Avenue ^ JCupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 `7UPEkTINO Building Department JOB ADDRESS: PERMIT # t-4-Who DPI . 0 �� 3 v OWNER'S NAME: ' ►tet e-Lc.Ar t,4 Av4 PHONE #(,510 (o ! - q 0eq 4;- GENERAL CONTRACTOR: PL-LA1,4;fa AX # [;( 0) &(o t - CX' -;4 C 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 Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date