09010047 CITY OF CUPE TING
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS:
21695 REGNART RD SANDI nc)01 n047
PERMIT ISSUE DATE
OWNER'S NAME:
S A CONTROL NO.
408) 894-9072
BUILDING PERMIT INFO
ARCHITECt7ENG1NEER:
BLDG ELECT PLUMB MECH
0 � 0
u o p LICENSED CONTRACT'OR'S DECLARATION Job Description
v I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business and Professions and my license is
y in full force and effect ] `� FURNC RPLCMENT & PARTL DUCT REPLCMNT
nZ License Class �•x
F-a Dam Contractor
A CHnECrS DECLARATION
1 understand my plans shall be used as public records
�yU
4 Q y Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
in O following mason.(Section 7031.5,Business and Professions Code:Any city or county
K 1 0! which requires a permit to construcE,alter,improve.demolish,or repair any structure
n yY prior to its issuance,also requires the applicantfor such permit to file a signed statement Valuation
< that he is licensed pursuant to the provisions of the Contractees Lictnse Law(Chapter 9 Sq.Ft.Floor Area
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or $7000
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 Civil penalty of APN Number Occupancy Type
not more than five hundred dollars(SSoo). 35624040 . 00
0 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 Required Inspections
and Professions Code:The Contractor's License Law docs not apply to an owner of
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.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Lb-
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.
0 I am exempt under See .B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
,ntion,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
0 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 WorkerLom naation Insurance carrier and Policy number am:
Cartier. tt'`'-- Policy No.:W SODO
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for anc hundred dollars($100)
Cir Iesa)
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 Workers Compensation provisions of the Labor Code,you must
z forthwith comply with such provisions or this permit shall be deemed revoked.
z OCONSTRUCTION LENDING AGENCY
(~i C/1 1 hereby affirm that there is a construction lending agency for the performance of
(lei 5 the work for which this permit is issued(Sec.3097,Civ.C.)
Wfs.A Lenders Name
z [.enders Address
V 0 I certify that I have read this application and state that the above information is
LL rr correcL I agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes
CL (We)agree to save,indemnify and keep harmless the City of Cupertino against
rF.r liabilities,judgments,costs and expenses which may in any way accrue against said City
V z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE ULATIONS.
,b 1.2Tm Re-roofs —
Signature of App rcanUCommctor Dale T of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
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 Safety
Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
0 Yes
Will a roof is installed without first obtaining an inspection,I agree to remove
ll the applicant or future building occupant use equipment or devices which
t hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
.strict?
0 Yes Nv
1 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 the building
does�notrmnfly haw a tenant,that it is my responsibility to notify the occupant of the
ch must x met to issuance of a Ccrtificatn:OCir capon Signature of Applicant Date
All roof coverings to be Class'J�"or better
Ownzed agent
Date
CITY OF CUPERTINO
7 ITEMS OF 14 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 35624040 . 00
DATE ISSUED. . . . . . . : 01/12/2009
RECEIPT #. . . . . . . . . . BS000006950
REFERENCE ID # . . . : 09010047
SITE ADDRESS . . . . . : 21695 REGNART RD
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER SANDIUM
ADDRESS 21695 REGNART
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4820
RECEIVED FROM . . . . : YIU-HANG LEE
CONTRACTOR MICHAEL LEE LIC # 28867
COMPANY SANDIUM
ADDRESS 4223 VERDIGRIS CIR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95134
TELEPHONE (408) 894-9072
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- -----
1BCBSC VALUATION 7, 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 7, 000 . 00 0 . 70 0 . 00 0 . 70 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40 .79 0 . 00 40 . 79 0 . 00
1MPERMITFE FLAT RATE 1 . 00 40 .79 0 . 00 40 .79 0 . 00
1MRRAA UNITS 1 . 00 61 . 19 0 . 00 61 . 19 0 .00
1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 .79 0 . 00 40 .79 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 226 . 05 0 . 00 226 . 05 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- -------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
CID9 C) 0 Y 7
CITY OF CUPERTINO
w FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN # � � Date:
Building Address:
Owner's Name: �-' Phone#: fig �7S
7 SI
Contractor: Phone#: 4os V4- Qa7 Z
Fax#:
Contractor License#: C� g l Cupertino Business License#:
Contact: 1„n p ( Phone#: i g �- q677—
Fax
672Fax #:
Building Permit Info:
Elect KJ- Plumb Mech
Residential Commercial
Job Description:
-Ftxy-V�6tcjZ., PCr
For Residential Installations:
Attic F-11St floor'[]--' 2°d floor ❑
Adhere to minimum setback requirement ❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: �+ Type of Construction (Usage Class):
7oo o l/
Strapped On Platform Bonded LJ New Location❑ Replacement
Project Size: Express Standard ❑ Large ❑ Major❑
Valuation:
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.
Revised 01/07/09
CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1MRAPPVNT Residential for the install/relocate/or M
replacement of ea appliance vent
install ¬ incl in an ap 1 permit.
FURNACE FURN/AC
1 PGASRES Residential for ea gas piping system of P
1-4 Outlets
1 BPGAS For each gas piping system of 5 or P
more per outlet.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Residential Seismic B
G
1MECPLNCK Mechanical Plan Check M
1MFR=<100 Furnace Syst<=100k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance up to and
include 100,000 Btu/h
1 MFRN>100 Furnace Syst> 100k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance over
100,000 Btu/h
1 EPERMITFEE Electric Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
1PPERMITFEE Plumbing Permit P
1TRAVDOC Travel Documentation B
1BUSLIC Business License B
INPUT Resources Energy AD
. n oor it ua ity an anis es
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
D
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Hsalth pts y=yes
7.Seal all Exposed Pargclebaard 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
i 1 1
N.Flooring
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 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
1 1 1
Total Points Available: 1 1401 1301 57
Taal Points Project Receive:
01 OF-11
G:data/progsJgreenbuildingguidelines/remodelers✓greenpointsfinal2.12.04protected.xis
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�MkTINO
Building Department
JOB ADDRESS:� -S � _ ,r PERMIT #07 0 I l,'�0 r, 7
OWNER'S NAME: w1- PHONE # `�' X72
GENERAL CONTRACTOR: � FAX #
I am not using any subcontractors: /( , /— _1
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
CITY OF CUPERTINO
BI!ILDINd DIVISION PERNIIT � � T '
BUILDING ADDR S: PERMIT NO.
19618 RICHWOOD DR FAST WATER HEA R09010094
OWNER'S NAME: PERMIT ISSUE DATE
ON S A CONTROL NO.
(800) 454-8955
ARCHrECr/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION Job Description
v I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business and Professions Code,and my license is R
y in full force and effect Mv RPLC GAS WATER HEATER
License Class Lle•M
F,O Date Contractor
ARCHITECT'S DECLARATION
ill 1 understand my plans shall be used as public records
Dku
tQ y Licensed Profrssional
L.n 3 OWNER-BUILDER DECLARATION
I hereby alTirm that I am exempt from the Contractor's License Law for the
E 120 following mason.(Section 7031.5,Business and Professions Cade:Any city or county
K m Pi which requires a permit to construct.alter,improve,demolish,or repair any structure
y Zy prior to its issuance,also mquims the applicant for such permit to file a signed statement Valuation
F=G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
yt.$ (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or $449
y .. that he is exempt therefrom and am basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mere than ere hundred dollars(M). 36908034 . 00
❑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 Required Inspections
and Professions Cade:The Contractor's License Law does not apply to an owner of fl 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 Contractor's la-
ccnse 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 Contractor's
License Law.
❑1 am exempt under Sec. B tit P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insum for Worker's Compen-
sation,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 wort for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Came Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section teed not be completed if the permit is for one hundred dollars($100)
or less)
1 certify that in the performance of the work for which this permit is issued.)shall not
employ any person in any mauncr so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,alter making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
`j.. forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
Hrte. I hereby afrirm that there is a construction lending agency for the performance of
(Y. the work for which this permit is issued(Sec.3097.Civ.C.)
W Q L.enrices Name -
? Lender's Address
U 0 1 certify that I have mad this application and state that the above information is
IL,0r amect 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
L1 t (We)agree to save.indemnify and keep harmless the City of Cupertino against
r�.t� liabilities,judgments,toss and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit Date
�+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
Re-roofs _
Signature of ApplicanUContractor Dee T of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
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 Safety
Cole.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
Will the applicant or forum 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.
-Astrict?
❑Yes ONO
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health k Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a certificate of Occupancy. Signature of Applicant Date
All roof coverings to be Class'W'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 36908034 . 00
DATE ISSUED. . . . . . . : 01/21/2009
RECEIPT # . . . . . . . . . BS000007013
REFERENCE ID # . . . : 09010094
SITE ADDRESS . . . . . : 19618 RICHWOOD DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER SHIPMAN WILLIAM T AND ELSIE B
ADDRESS 19618 RICHWOOD DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3315
RECEIVED FROM . . . . : JEFF JORDAN
CONTRACTOR JEFF JORDAN LIC # 29100
COMPANY FAST WATER HEATER
ADDRESS 12601 132 AVE NE
CITY/STATE/ZIP . . . : KIRKLAND, WA 98034
TELEPHONE (800) 454-8955
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 449 . 00 1 . 00 0 . 00 1 . 00 0 .00
1BSEISMICR VALUATION 449 . 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
----------------- --------------- --------------------
CREDIT CARD 107 . 56 VISA
---------------
TOTAL RECEIPT 107 .56
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER
D l ooq,i 430319
' Permiit No: 7-
(office usa only
City of Cupertino Building Permit Application
E-Mail: Building-Permits(a) uc pertino.ora (Address is case sensitive).
Jobsite Address:19618 RICHWOOD DR Date: 1/21/09
Assessor's Parcel Number: = q 0 �' 0 0
Owners Name: SHIPMAN,WILLIAM Phone No: (408)252-8692
Project Valuation: 449.00
Building Permit Info: Bldg_ Elect Piumb X Mech.
Job Description
Remove/Replace Gas Water Heater
Contractor Information
Company Name: FAST WATER HEATER COMPANY Phone No:
Contact Name: Julie Caskey Fax No: 425-636-7084
Address: 12601 132ND AVE NE E-mail:caroir(gfastwaterheater.-M
City, State &zip code: KIRKLAND,WA 98034
' State Contractor's Lic. No: 877489 Expiration Date: 5/31/10
Worker's Comp No: A09304455 Expiration Date: 12/1/09
Carrier: Truck Insurance Exchange
City of Cupertino Business License Na: 29100
Credit Card Information
Credit Card N Expiration Date: 11/10
Name on Card: Jeff Jordan
Visa ® MasterCard ❑ American Express ❑
The Building permit application and a completed & signed
contractorlsubcontractor form need to be submitted with each permit.
Community Development
10300 Torre Avenue
Cupertino CA 95014
TA#cw(408)Tn-3228
Fax(409) n7-3333
CUPERTINO
Buncung Department
JOB ADDRESS: 19618 RICHWOOD DR PERAW# c0O O OQ !I
OWNER'S NAME: SHIPMAN,WILLIAM PHONE# 408)252-8692 `
GENERAL CONTRACTOR FAST WATER HEATER COMPAN FAX# 425-636-7085
I am not using any subcontractors: 1/21/09
Signature Date
Please check applicable able 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
Lativng
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal. .
Sheet.Rock
Tile
Owner/Contractor Signature Date