09050081 CITY
OF CUPERTINO PERMIT BUILDING DIVISION PERMIT � �AQ � �� '
BUILDING ADDRESS: PERMIT NO.
938 LIBER ER
OWNER'S NAME: PERMIT ISSUE DATE
r0 SAN CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
REPLACE WATER HEATER 50 GAL
u p p LICENSED CONTRACTOR'S DECLARATION Job Description
U p I hereby affirm that I am licensed under provisions of Chapter 9(commencing
I Z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is
H in full force and effect
j License Class ---3 b Lie.I
Dale IV- o 5 Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
�U,
O11 Licensed Professional
N 3 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
c p O following reason.(Section 7031.5,Business and Professions Calc:Any city or county
K,s, which requires a permit to construct,alter,improve,demolish,or repair any structure
z�y prior to its issuance,also requires the applicant for such permit to Ole a signed statement
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 civil 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 sale(Sec.704t,Business Required Inspections
and Professions Code:The Contractor's 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.).
[11,as owner of the property.am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
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 Contractor's
License Law.
❑1 am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby alum under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Workers Compen-
sation,at provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 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 Ingurance carrier and Policy number are:
Cartier t %.�cx Policy No.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need notbe 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 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 0 Lendces Name
Z Lender's Address
U O 1 certify that 1 have read this application and state that the above information is
LL Er cortcct I agree to comply with all city and county ordinances and state laws relating to
0 building construction,and hereby authorize representatives of this city to enter upon the
a above-mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Hliabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. /)
►+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b}: Date
SOURCE G CATIONS.
(/��J -' -- j' o4 Re-roofs
Si nature of A cant/co for Da
g 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 Safety
Cale,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
If a roof
Will the applicant or future building occupant use equipment or devices which
.s installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes NNu
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 the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements use be �isertificate of Occupancy. Signature of Applicant Date
Owner mrizcd f Date All roof coverings to be Class'A!'or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
XPEkTINO
Building Department
JOB ADDRESS: PERMIT#
'73s, '-L"60-22r7
OWNER'S NAME: PHONE # Z t 0 3 a—,!c
GENERAL CONTRACTOR: FAX#
I am not using any subcontractors:
e Date
Please check applicable subcontractors and corn. lete the following information:
SUBCONTRACTOR BUSI:4ESS 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
S--Ir.
_.IS. 0c)
Owner/ a afore Date
CITY OF CUPERTINO
WATER HEATER
CUPEi�TINO PERMIT APPLICATION FORM
W05
APN # y Date:
Building Address:
r�3st Lt5�
Owner's Name: Phone #:
Contractor: Phone #: Q-4
Fax #:
Cupertino Business License #: Contractor State License #:
FRS k \« 1
Contact: Phone #:
Fax #:
Building Permit Info:
Plumb
Elect [ Mech
Bldg � �"
Residential a Commercial ❑
Job Description: �'►�= ��' '�f N
Strapped ❑ On Platform ❑ BondeC New Location ❑ Replacement
Valuation (cost of project):
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:
Revised 01/07/09
CITY OF C[,�PERTINO
R. ..y WATER y[EATER
an Of ATION FORM
CUPE �TINO I
s
Fee Permit Type
Quantity Fee ID Fee Description Gros
IPC ATR Commercial "h ater
B pCWHEATR
HeaterNent B ALL PERMIT TYPES
1BCBSC Cal Bldg Standards
Commission Fee
1BSEISMICOM
Seismic Comrlercial B
1PRW14EATR Residential Water B
pRWHEATR
Heater/'*ent B ALL PERMIT TYPES
1BCBSC Cal Bldg Standards
I Commission Fee B
1BSEISMICRE Seismic Residential
I
1 ppERMITFEE Plumbing Permit P
r
1
1 TRAVDOC
Travel & B
Documenta-.ion B
1BUSLIC Business License
M.Indoor Air ua dy and imshes 0
1 IACyHealth pts Y=YeS p
1.Use LDW No-VOC Paint 2 IAQ/Health pts y=yes
2.Use Low VOC,Water-Based Wood Finishes 0
31AQIHealth pts y=yeS 0
3.Use LowlNo VOC Adhesives Resource pts y=yes
4.Use Salvaged Materials for Interior Finishes
0
5.Use Engineered Sheet Goods with no added Urea Ei IAQ/Health pts y=yeS 0
Formaldehyde IAQ/Healthpts y=yes
6.Use Exterior Grade Plywood for Interior Uses 0
paaticletx�ard or MDF t IACyHealth.pts y=yeS 0
7.Seal a8 4 Resource pts y=yes
B.Use FSC Certified Materials for Interior Finish 0
1 Resource pts y=Yes 0
9.Use Finger-Jointed or Recycled-Content Trim 3 IA(yHealth pts y=yes
10.Install Whole House Vacuum System .
N.Flooring 0
3 Resource pts y=YeS 0
1.Select FSC Certified Wood Flooring 4 Resource pts y-yes
2.Use Rapidly Renewable Flooring Materials 0
4 Resource pts y=yeS 0
3.Use Recycled Content Ceramic Tiles 5 IAQ/Health pts y=yes
4.Install Natural Linoleum in Place of Vinyl 0
4 Resource pts y=YeS 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts yges
l -
6.Install Recycled Content Carpet with Low VOCs ' ,
140 130 57
Total Points=Avai 0
0 0
Total Poin�Ppro*�ecteceived:
sir 07
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