09050149 CITY OF CUPERTINO �r INRTI1 :
BUILDING DIVISION PERMIT
PERMIT NO.
r
ING ADDRESS: n1 4910375 MORETTI DR CALVIN&B -0 PERMIT ISSUE DATE
R'S NAME: INC
' S IA CONTROL NO.
(4 0 8) 58 -4 9 8 8 BUILDING PERMIT INFO
BELECT� PLUMB7 M
ECH
ARCHITECffENGINEFR: �
a C Z LICENSED CONTRACTOR'S DECLARATION Job Description
UI hereby affirm that I am licensed under provisions of Chaptc and m(commencing cense is —
Z with Sccdon 7000)of Div'•on 3 of the Business and Professions C y RE PLC WAr['R HEATER (GAS, TYPE, NATURL GAS)
01,4 a in full force an tffec�
M l icense , �' e °Contractor #3 0 0 4 7,
° °etc CHITECI'SDECLA A 1 ru f` CALVIN & BROS CONST RENEWD BUS LIC
I understand my plans shall be used as public records
5 W U
4 O y Licensed Professional
OWNER-BUILDER DECLARATION
n r-t 1 hereby affirm that I am exempt from the Contractor's License Law for the
ty or county
p O following reason.(Section 7031.5,Business and vre f demolish. r repair Any t y sw tune Valuation
14 9 which requires a permit to construct pplisliecanl for such permit to file a signed statement $ Ft.Floor Area
u"0 prior to its issuance.also requires the app
i that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 11
°Y. (commencing with Section 7000)of Division 3 of the Business and Professions Code)or Occupancy Type
y $ that he is exempt therefrom and the hasrsmfor d e app)caantto a civil n.Any tpenalty of APN Numbeolation of r
Section 7031.5 by any applicant for a Pe subjects
not more than five hundred dollars(SM. 37514012 . 01
0 I,as owner of the property.or my employees with wages as their sole compensation, Required Inspections
will do the work and the swcture isnot intended or offered for sale(Sec.7044,Business
and professions Code:The Contractor's License Law docs not apply a an owner of
property who builds or improves t►rari on,and who does such work himself or through his
own employees,Provided that such improvements are not intended m eon the for ovmer-
however,the building or improvement is sold within one year P
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
0 I,as owner of the property am exclusively contracting Cod,withlicensed)Th contractors t.
construct the project(Sec.7044.Business and Professions
who build improves °s 4
cense Law does not apply a an owns of property pursuant a the Convector s
who contacts for such projects with a contractors)licensed p
License Law. B&P C for this reason
0 I am exempt under Sec.
Date�—
Owner
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-insure for Workefs Compen-
.on,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued
0 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.
ber 2�
My Workers CC ratio sumnce artier and Policy num
Cartier _ Policy No.:
FI 01k TION ON RAN OM ERS'
(ILis section need 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 shoo
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J'f-, forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
H— 1 hereby affirm that there is a construction lending agency for the performance u[
pG> the work for which this permit is issued(Sec.3097.Civ.C.)
Lt7 MLender's Namc
04 Lender's Address
C:3 Z
)0 I certify that I have read this application and state that the above information is
LL cortcct I agree a comply with all city and county ordinances and stale laws relating a
building construction,and hereby authorize representatives of this city a enter uPon the
V above-mentioned property for inspection purposes
u� nWi (Wc)agree to save,indemnify and keep harmless the City of against
against J _
liabilities,judgmcns,toss and expenses which may in any way accrue against said City Date �j
in consequence of the granting of this permit.
V Z .
UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b
SOURCE REguNS. Re-roof!
Date Type of Roof �•�
Signature of pQlic. t/Contractor
HAZARDOUS MATERIALS DISCLOSURE
W,II the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12.and tltc Health and Safety
Code,Section 25532(a)? , � All roof 3 shall be inspected prior to any roofing material being installed.
❑Yes VN. If a root is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which all new materials for inspection.
,it hazardous air contaminants as defined by the Bay Area Air Quality Management
arict? �
O Yes 9a".
Lad the hazardous materials requirements under Chapter 6.95 of the Califor-
ty Code,Sections 25505.25533 and 25534.1 understand that if the building Date
ly have a tenant,that it is my responsibility to notify occupant of Signatu-e of Applicant
' m m t •ora issuance of a Certificate of cup cy.
Z� 2 ee All roof coverings to be Class'W'or better
Date
rized cm
CITY OF CUPERTINO
WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN # t-5— l L D
Date: ja 6 /aoo
Building Address:
p Y�)ore tu �I`ve C4r i h D CA I
Owner's Name: Phone #:
4oO 446 -- 4I 3 �
Contractor: Phone #:
C'W� °Y> Fax #:
r
Cupertino Business License #: Contractor State License #:
�Ll� !0 774
Contact: Phone #:
Fax #:
Building Permit Info:
Bldg Di El Plumb [�'� Mech
Residential Nf Commercial ❑
Job Description: `
Strapped On Platform ❑Bonded New Location ❑ Replacement
Valuation (cost of project): L
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 CUPERTINO
`lam` WATER
HEATER
Of
CUPERTINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Permit Type
Group
1 PCWHEATR Commercial `'Vater B PCWHEATR
HeaterNent
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission 1,ee
1BSEISMICOM Seismic Commercial B
1 PRWHEATR Residential Water B PRWHEATR
Heater/Vent
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission I�ee
1BSEISMICRE Seismic Residential B
/ 1 PPERMITFEE Plumbing Pennit P
1 TRAVDOC Travel & B
Documentation
1 BUSLIC Business Lice:ise B
M.Indoor Air Quality and Finishes INPUT Resources Energy IA-D/Health
1.Use Low/No-VOC Paint 1 IAQ/Health pts y=yes 0
2.Use Low VOID,Water-Based Wood Finishes ?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 5IAQ/Health pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7.Seal all 6posed Particleboard or MDF 4 IAQ/Health. pts y=yes 0
6.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
. 1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring E 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 !)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
li
Total Points Available: 1 1401 130 57
Total Points Project Received: —4,10 01 0
w
� 2.6 z6o
G:data/progs/greer buildngguidefines/remodelers/greenpoi fina12.12.D4pmtected.xIs
Community Development
a 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
-CITY OF Fax(408)777-3333
`'UPEkTINO
Buildiia De artment
JOB ADDRESS: �D 37 b� `�r�VQ, (& PERMIT 41
OWNER'S NAME: PHONE # d 4F --3
GENERAL CONTRACTOR: Co" k ox FAX#
I am not using any subcontractors: ( -�
Signature Date
Please check a licable 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