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12110147 CITY OF CU13ERTINO BUILDING PERMIT BUILDINGADDRESS: 10515 FARALLONE DR CONI'RACI'OR:PAYLESS WATER PERMIT NO: 12110147 HEATERS OWNER'S NAME: LANCE ROBINSON 24895 AVENUE ROCKEFELLER DATE ISSUED: 1128/2012 OWNER'S PHONE: 614-975-94 VALENCIA,.CA 91355 PHONE,,NO:(661)7754944 LICENSED CONI'RACI'OR'S DECLARATION 3011 DESCRII''1'ION: RESIDENTIAL COMMERCIAL, r License Class� C3�0 Lie.N 931oat o REPLACE 40 GAL WATER HEATER IN SAME LOCATION l Contractor - a.Q LQS`7 Date I,'Z g-lL I hereby affirm that 1 am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a cenificale of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of die Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$1000 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 ANN Number:36939031.00 Occupancy'1'ypc permit is issued. AI'PLICANT CER'fl1'IC•\9'ION 1 certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property_for inspection purposes. (We)agree to save 180 DAYS AST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, I costs,and expenses which may acerae against said City in consequence of the II granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. f, Date I� R roofing FS: Signature _ All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNFR-BUILDER DECLARATION Signature of Applicant: Date: 1 hereby affirm that I am exempt from the Contractor's License Lm, for ane of the following two reasons: ALL ROOF COVERINGSTO BE CLASS'S\"OR IWITER 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&.Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to IIA%ARDOUS MATERIALS DISCLOSURE, construct the project(Sce.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the California Ilealth&Safety Code.Sections 25505,25533,and 25534. 1 will 1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.I'_and the declarations: Ilealth&Safety Code,Section 25532(1)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Ray Area Air Quality Management District performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the I Iealth&Safety Code,Sec ions 25505.2$533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner onaueg thorizeden hJ Date:11,70 permit is issued. - 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 Worker's Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGF.NC\' become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address - 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 Ira 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 .AHCIIITECI"S DECLARATION and keep harmless the City of Cupertino against liabilities,judgments. costs,and expenses which may accrue against said City in consequence of I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 CUPERTINO _ Fax: 408-777-3333 CONTRACTOR !SUBCONTRACTOR LIST JOB ADDRESS: lD51J FarMloOL Pr PERMIT# OWNER'S NAME: P kala r .I ►Yl 13151(1 PHONE# GENERAL CONTRACTOR: BUSINESS LICENSE# _ ADDRESS:,PygQ�;' CITY/ZIPCODE: c'la �jSS *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. AQ�� /� p 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 Painting/ Wallpaper Paving Plastering Plumbing } Roofing Septic Tank Sheet Metal j Sheet Rock I Tile l-z�7 Owner tContractor Signature Date Prescriptive Certificate of Compliance: Residential WATER]HEATER CF-IR-ALT-Water Heater Date: Enforcement Agency: Climate Zone # # of Stories Permit # 1- Z7-1Z 12 Site Address: 165 Is f-a ra- I I DIL Pr Building Type t Single Family ❑ Multi Family NOTE: This form is not to be used or Newly Constructed Buildings or Additions WATER HEATING List water heaters and boilers for both domestic hot water(DHW) heaters and hydropic space heating. Individual dwelling DHW heaters must be gas or propane fired, and may not exceed 50 gallons. Hot water pipe insulation from the DHW heater to the kitchens) and on all underground hot water pipes is required in all component packages in all climate zones. Water Heater Type/ Distribution Type Number Tank Energy Factor External Fuel Type' (Standard, in System Capacity or Tank Recirculating)2 (gal) Thermal Insulation Efficiency R-Value3 0.fG OL s SIGndG l (v 1. Indicate type(Storage Gas, Heat Pump, Instantaneous, etc) 2. Recirculating systems serving multiple dwelling units shall meet the recirculation requirements of §150(n). The Prescriptive requirements do not allow installation of recirculating water heating system for single dwelling units. 3. The external water heating tanks and pipes shall be insulated to meet the requirements o 150 ' . Declaration Statement • 1 certify under penalty of perjury,under the laws of the State of California.the information provided on this form is accurate and complete. • 1 certify that the energy features and performance specifications identified on this Certificate of Compliance conform to the requirements of Title 24,Parts I and 6 of the California Code of Regulations. Name: � Signature: !�. luRuht� b,toGlkS Company- Date: a less (-(,zr l )- Z 7-1 z Address: License: aus9g auelnue 2��Lol, 9*-3oatCa City/State/Zip: Phone: UOl,z♦'&L Ql35, (0(91 77- -2,CW i For assistance or�questions regarding the Energy Standards, contact the Energy Hotliue at 1-800-772-3300. 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