13040047 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20810 PEPPER TREE LN CONTRACTOR:CALIFORNIA DELTA PERMIT NO:13040047
MECHANICAL INC
OWNER'S NAME: MICHELE LUM 6056 E BASELINE RD STE 155 DATE ISSUED:04/04/2013
OWNER'S PHONE: 4085204241 MESA,AZ 85206 PHONE NO:(866)692-5273
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIALEI
License Class - Lic.# l�fl� � REPLACE(E)WATER HEATER,SAME LOCATION
Contractor,L'e,/,'� &ate
I hereby affirm that I am licensed under the prAons of EIF110ter 9
(commencing with Section 7000)of Division of the Business&Professions
Code and that my license is in full force and'effect.
I hereby affirm under penalty of perjurybne,of the.following two declarations:
I have and will maintain a certificate of consent,to'sel£insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$1500
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 APN Number:35911041.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I 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 FR LAST CALLED INSPECTION.
indemnify and keep harmless the City,of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,.the applicant understands and will complyIssued _ Date: 5
with all non-point source regulations per,the Cupertino Municipal Code,Section
9.18. E
RE-ROOFS:
Signature ,- —� Date 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.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intendedor offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the-following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)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 Bay Area Air Quality Management District I
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 Health&Safety Code,Sections
�25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: %��- l Dater
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 AGENCY
become subject to the Worker's Compensa tion 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 thi's,perinit 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 laws 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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the 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
GENERAL PERMIT APPLICATION MER
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTI NO,CA 950143255 O
CUPERTINO (408)777-3228•FAX(408)777-3333• building a5cuDertino.org \� MISC
PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS C AMn 35 ,?
5Q — / / 6 C-/
OVl'NERNAME � e /G f PHONE E �
ST�RECTADODRESS P// �iG P CIjYGST TEG 9 ��D I /! FAX
CONTACT T L,yh/L P{�0NE — s E-MAIL
Z!Y
STREET ADDRESS CITY,STATE,ZIP FAX
❑ ORRIER ❑ OWNER-BUILDER ❑ OWNERAGENT "CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
T NAME LICENSE NUMEER LICE:0 T1 P BUS.LIC
=rte v �e n � 1 /
COMPANY NAME E-MAIL FAX
S RES CITY,STATE,ZIP PHONE
ARCHITECT/ENGATEER NAME LICENSE NUMBER BUS.LIC 4
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY - PROJECT IN WILDLAND ❑ YES PROJECT IN EI YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL - URBAN INTERFACE AREA [3 NO FLOOD ZONE
❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION: (� ` IVED
By my signature below,I certify to each of the following: I am the property owner or au zed agen I have read this
application and the information I haveprovided is ct. I have read the DescTiP6oa-ofV6rk and verify it is accurate. I agree to comply With all applicable local
ordinances and state laws relating to buildin on. I auth resentatives of Cupertino to enter the above-identified propefty for inspection pui`poses.
Signature of Applicant/Agent: Date:
L MENTAL INFORMATION REQUIRED OFFICE USE ONLY
❑ OYER-THE-COUNTER
❑ EATRESS
U
'� ❑ STANDARD
U
❑ LARGE
LEI HSAJOR
AHPA1iscApp 2011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 20810 PEPPER TREE LN DATE: 04/04/2013 REVIEWED BY: MELISSA
APN: 35911041 BP#: "VALUATION: 1$1,500
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: PRWHEAT
WORK REPLACE (E)'WATER HEATER SAME LOCATION
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Heater 1PRWHEATR 1 # $27
1
TOTALS: $27.0017Bw 104-z'
r
Nfech. Plan Check Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check
llech.Permit Fee: Plumb.Permit Fee: IPPERMIT I lec. f ernzit Fee:
Otho•Alech.Insp. Other Plumb Insp. 0.0 hrs $45.00 Oiher Elec.Insp.
14ech.Insp.Fee: Plumb. hisp.Fee: Elec.Imsp,Fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). Theseees are based on the mina information available and are onlyan estimate. Contact the De t or addn'l info.
.FEE ITEMS(Fee Resolution 11-053 E f 7/1/121 FEE QTY/FEE MISC ITEMS
Plan Check Fee:
S fppl. PC Fee
PME Plan Check: $0.00
Permit.Fee:
SupI-)I. Insp Fee.
PME Unit Fee: $27.00
PME Permit Fee: $45.00
Consli-tiction :Tax.
Administrative Fee: IADMIN $42.00
Work Without Permit? 0 Yes 19 No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRAVDOC $45.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldy,Stds Commission Fee: 1BCBSC $1.00
50.
$160 $0.00 E.
� , $1.60.50
Revised: 04/01/2013
3
Prescri tive.Certilcae of Cont lattcc:Residential; Cl!-l'R-ALT
ResidentfclAlter'trt t_rs WATER HE_ATER,REPLACEMENT (Page 1 of 1)
Project ltam Climate Zone# #of Stories
c (. 1 C r7Ce
r.
G'eriernhinfor�ition i
Site Address, Enforcement A elle ;� Date:
Building Type 81n9fe:6mily Cl lvlultf Family Circle the Front Orientation:N,G,S,W,or degrees
Project Type: 0 Alterations 0 Envelope❑Fenestration ❑Roof
Conditioned Floor A7ea(CFA); HVAC Replacement or Change Out ❑Duct Replacement)!4vater
Heater
/VOTI TltirfnrEi tt'iatrtOh; �rNalt'fy Gottslrrtcled f3rdliliugs or Additions
WATER FIEArT1NG
Gist water heaters wird bolleis f(ir broth r(i+nesii(•htt water i7Jflii')herac"ri turd hydronirspirre heating. 111dii•irhurl dn2tling I HIV heaters must
be gos ar-jrrupan +ui e ft.+et�ctftttrf oral i'veead 50 gathms. Hot-tvruer•pipe bistlatiou front the MAt'heater to the kilehen(s),tid oirall
tndc gru+md hot wateryMpes 1.1,,rer fired a tall rani rure+u eickaxec in till elinture tines:
External Tank
Willer Nlcater 1 ypelHucl Distribution Tyne Number in Tank tnergy Factor err insulation
TYP4 (Stmtilard.Recin ulatingj' System Canacitmgap Thermal Efficiency R-Value'
2
1.bidletie frirc'f lrita s Ctrte,`Ifetihl'ret'ip,iltc&nrtiinc+oas,ea.)
3.Rerirctduung sissirtttis rer4}r`li) tuiltipie thrallith+-rrrrtls,dtall"ntec7nc�fzcfrcalritlnu req+rirrrnenZr' r1;50(+r). The Prexcli,tile I-equiretrenisdo
anl_allow rhe urx{it)lutrnt a(h min uldting orricrr)itatrttng ky:atrrn jrrr ti ngEc du irNing unite
3.The erre„tal reale€Itc tYin%;iitrik..anrl"i ress/rallCbe insiditteidwi meet Me req uireinews q1'.050(j),
Contractor's;(Doctitiinnttitiott<Aptirar'S/Respdasiirle Building Designer's/Owner's),Declaration Statement
• I certify that,thirCertif'(,**,of Compliance is accurate and complete.
1 ant eligible under l)ivisi"on 3 of the Californfa.Business.and Professions Code to accept responsibility for the building
design identiFieci-on:this Ct rtifcatt of Compliance
• i certify that the€ter-gy;features upd perfo'rmnnce sp ificaut)ns,for tlie:builciinedesigri identified on this Certificate-ol•
Compliance conform to the requirements of Title 24,Parts l and 6 oft'he California Code of Regulations,
• The,'bwldtn rleslsn.foatures idelitified ort this Certificate ortompliance are consistent with the information provided to
document lhis building design cin the,other appticai is cotiipiiancc forms,worksheets.calculation fans and specifications
submitted torlhe erforeement a*encfdra royalwith this bttildin> ermit iAl
Name:
Signatnra l �� 'lxt
Company: ate:
Address: Licenses
City/State%Zip. Phone:
8Pe� •ct73. 3 592,
ror assisidnee or?treftidits regarding Me Errergy- taridards;t vrrtact the Eller gY flolline(it:1-800-772-3300.
1
E
JWrALLATIONCtk`f.IF[CATT. Cr-61R-It7LCH-01
Domestic Hotati D.HW (Pae 1 of 2)
Site Address: Enforcenient Agency- Permit�Inmber:
Q 1a o
1. WATER HEXTIN SYS, D,$:
DWribution RatcJ d
I CEC Tylse Lt lot' Input(kW Tank Standby
Ileater fi Ctti6cdMfiNiune&Model (Std point-of- Recirculation, Identical tot volume Efficiency LOSS
Type f t�{uivUer Use.etc) Contwl l'" e S�atetns BwAir) (gallon») (t-f.RE) 0110)
TV
are/ For snail!gassiarage(rated input teas than at-equal to 75.000 Rialho,electric resistance and heat pump water healers,list
Fdtergi,Factor`-(EF). Far 144e gas staeage:waler heaters(rated inpar of greater than 75.000 Diu--lug,list Recovery F,fJidenc'v(RE).
Thermal Efc�len&vu StanelbvLatsandKdedhiput. For Ltsurntatteotrs;nswgterkealers.list rite Ttretntal GJJicicrtc) and Bitted[nptu.
2. Mandatory Measures
.1.0 COMPLY-ALL H.OXE�S W ST RECHECKED
§110-§113't,Udater,heaters,showerhead and faucets are certified by the California Energy Commission.
§150(0):Water'System Pipe andTank his tlation..And Cooling Line Insulation
1. Storagd'tank insutation
A..Storage gas Mater heaters rated with an Energy factor no greater than the federal minimal standard are
externally-wrapped'with insulation having an installedthermal resistance of R-12"or greater,and
B. unfired storage wanks or other indirect hot water tanks have R-12 external insulation or R-16 internal
insolation:where the internal'insulation R-value is indicated on the exterior of the tank.
2. Water piping and eootingsystem line insulation thickness and'conductivity
First 5 feet ofhot`:and cold-,water pipits closest to water heater tank,non-recirculating systems,and entire
length of reeirculltina sections of hot water pipes are insulated per Standards Table 150-B;and
Pipe,insolation for steam hydronic heating systems or hoc water systems>15 psi,meets the requirements of
Standards Table 123-A.
Insulation is protected from damage,including that due to sunlight,moisture,equipment maintenance,and
wind.
§151(081 tAf indicated on>the C1-'-1 R,all hot water piping that runs from the hot water source to the kitchen fixtures is
insulated per Standards Table 150-B.
2008 Residential(;on)xtliance Form -I1rgtrrl 2009
s
TNSTALLATIUN CECtTIFICATE CF-6T2-MECH-01
Domestic lot Water D ilW) Page 2 of 2)
Site Address: Enforcement Agency, Permit Number:
3. Central Witter Heating in Buildings With Multiple Dwelling Units(required for prescriptive)
TO COMPLY.ALL BOXES MUST BE CHECKED
All hot water pip tng,in'main circulating loop is insulated to requirements of§1500)
Cent,d)hot 4r't1hS't systcnts serving six or fewer dwelling units which have(t)less than 25`of distribution piping
outdoors,(2)zet o distribution piping underground;(3)no recirculation pump;and,(4)insulation on distribution
Piping that itt.eets thio requimments:of Section 1500)
Centra)hot water systems serving more than 6 dwelling units-presence of either a time control or a.
dmettetnperaturt control'
DECLARATION STATEMENT
• 1 certiN under penulty,of penury,-under the,laws of the State of California.the information provided on this form is true and correct.
• 1 am eligible:undee Division 3 of'the 13usiness and Professions Code to acceptresponsibility for construction.or an authorized
representative cif the:person resp nsible for construction(responsible Person).
• t eeinty thattl e.instahtd Featutt s,materi xls campanents,or manufactured devices identified on this certificate(the installation)
conforms to all applicable codes and re-uhitions.and the installation is consistent with the plans and specifications approved by the
eni'oreement agency::
• I reviewed acopy ol`the Certificate.ofCompliance(CF-lit)form upproved by the enforcement agency that identifies the specific
requirements forthe installation. 1 certify that the:requirements detailed on the CF-1 R that apply to the installation have been met.
• I will ensure:that a completed,signed copy of this Installation Certificate shalt be posted,or made available with tite building
permit(s)issued 6r,the building,and made available to the enrorcement agency for all applicable inspections. I understand
that a signedcoRy of thls installation Certificate is required to be included with the documentation the builder provides to
Lite building oviitter.at.occupancy.
Company Name: (htsiallii g 3ubcontiactor or General Contractoe or Builder<tOwne
Responsiblepersonshtame: spgnsr
ale-
CS L.l3 I Icense I Dates Siencd: posftian luit t('a t am„(7 itic):
2008 Resrcleali(#Cant licrrzre ftjirnrs
�. :f irgust'_009