13040054 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10456 JOHNSON AVE CONTRACTOR:SUNGJU CHO PERMIT NO:13040054
OWNER'S NAME: SUNGJU CHO 10456 JOHNSON AVE DATE ISSUED:04/05/2013
OWNER'S PHONE: 4087442561 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL
License Class Lic.# REMOVE AND REPLACE ELECTRIC WATER HEATER TO
GAS
Contractor Date WATER HEATER IN SAME LOCATION
I hereby affirm that I 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 certificate of consent to self-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:$580
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:37526045.00 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 WIT I�T 80 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 DA OM LAST CALLED INSPE L.
Issued b /3
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 comply y Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
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 myemployees 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 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, 5533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent: Date:
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 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 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 re ptstions per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Date
Signature
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISIONbo
.10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228-FAX(408)777-3333- building a5cuDertino.org MISC
❑PLUMBING ❑MECHANICAL ❑ELECTRICAL —]MISCELLANEOUS
PROJECT ADDRESS j D f (� n �'T JI✓� mo I APN#
! (7 *CEJ' o OVI NER NAME G°�X J Lt C/�40 PHONE �� E-MAIL1'f� jiz, ®quo
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STREET ADDRESS lo
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•-fa A� /1-� CITY, STATE,ZIP (kO (A
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cohrrAcr NAME �t( ✓ CL /"IV PHONE �Q& E-MAn St,{ ul�:,Xx C-0,4
c/STRREET ADDRESS ( �'Td N� ,�(- CITY,STATE,ZIP Ktl C.4 VDIA FAX
L1 oI1'NER ❑ ON'N`ERO-BUILDER`/ ❑OWNER AGENT
❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC n
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTT-FAMILYPROJECT IN WILDLAND ElYES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
7 m�ev►f ret014 -fd -We Z M i
A,osft6c7t..q wafeV'
TOTAL VALUATION: � RECEIVED B
By my signature below,'I certify to each of the following: I am the property owner or authorized agent to act on the pro rty o-,vner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurat agree to comply with all applicable local
ordinances and state laws relating to building con ction. I authorize representatives of Cupertino to enter the above-I entified�.prope6 for inspection pufposes.
Signature of Applicant/Agent: Date: AbdS
SUPPLEMENTAL INFORMATION REQUIRED OFFICE ' NLY
OYER-THE-COUNTER
❑ EXTRESS
U
u ❑ STANDARD
U
❑ LARGE
❑ MAJOR
AI PAdiscApp 2011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10456.johnson ave DATE: 04/05/2013 REVIEWED BY: Mendez
APN: BP#: *VALUATION: $580
xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Repair
PRIMARY SFD or DuP lex PENTAMATION PRWHEATR
USE: PERMIT TYPE:
WORK remove and replace electric water heater to gas water heater in same location
SCOPE
# cm
win
Afech.Ilan Check Plumb.Plan Check 0.0 hrs $0.00 Elec..Plan Chock
:tech.Pera it Fee: Plumb.Permit Fee: LJO0
L;tec.,Permit Pee:
C)thr� ;.larch.Insp. Other Plumb Insp. 0.0 hrs (Ither Elec.Insp. Li
Wech.Ills]).Fee: Plumb. Insp.Fear• Elec.Insp. Fee:
NOTE:This estimate does not include fees due to other Departments(i.a Planning,Public Works,Fire,Sanitary Sewer District,School
District etc). Theseees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS(Fee Resolution 11-053 Eff. 711112) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 0 # Plumbing
Suppl. PC Fee: (F) Reg. 0 OT 0.0 hrs $0.00 $27.00 IPRWHEATR Water Heater
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee G Reg. ®OT F0,_0hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $45.00
Conoraction Tax:
Administrative Fee: 1ADMIN $42.00
Work Without Permit? ®Yes (j) No $0.00 0
Advanced Planning Fee: ' $0.00 Select a Non-Residential
Travel Documentation Fee: ITRAVDOC $45.00 Building or Structure
i
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
- _ $133.50 $27.00 $160.50
$160.50
Revised: 04/01/2013
INSTALLATION CERTIFICATE CF-6R-MECH-01
Domestic Hot Water (Page 1 of 2
Site Address: l�� �u kE Enforcement Agency: Permit Number:
1. WATER HEATING SYSTEMS:
Distribution Rated
CEC Type If #of Input(kW Tank Standby
Heater Certified Mfr Name&Model (Std,Point-of- Recirculation, Identical or Volume Efficiency Loss
Type Number Use etc) Btu/hr)1 (gallons) (EF,RE)i (°/n)t
Ole- 4o QX 12,p%
qaS Wafer ti eY
Note 1:For small gas storage(rated input less than or equal to 75,000 Btu/hr),electric resistance and heat pump water heaters,list
Energy Factor(EF).For large gas storage water heaters(rated input of greater than 75,000 Btu/hr),list Recovery Efficiency(RE),
Thermal Efficiency,Standby Loss and Rated Input. For instantaneous gas water heaters,list the Thermal Efficiency and Rated Input.
2. Mandatory Measures
TO COMPLY-ALL BOXES MUST BE CHECKED
❑ §110-§113:Water heaters,showerhead and faucets are certified by the California Energy Commission.
§1500):Water System Pipe and Tank Insulation.And Cooling Line Insulation
1. Storage tank insulation
❑ A.Storage gas water heaters rated with an Energy Factor no greater than the federal minimal standard are
externally wrapped with insulation having an installed thermal resistance of R-12 or greater;and
❑ B.Unfired storage tanks or other indirect hot water tanks have R-12 external insulation or R-16 internal
insulation where the internal insulation R-value is indicated on the exterior of the tank.
2. Water piping and cooling system line insulation thickness and conductivity
❑ First 5 feet of hot and cold water pipes closest to water heater tank,non-recirculating systems,and entire
length of recirculating sections of hot water pipes are insulated per Standards Table 150-13;and
❑ Pipe insulation for steam hydronic heating systems or hot 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.
❑ §15 1(f)813:If indicated on the CF-1R,all hot water piping that runs from the hot water source to the kitchen fixtures is
insulated per Standards Table 150-13.
2008 Residential Compliance Forms August 2009
INSTALLATION CERTIFICATE CF-6R-MECH-01
Domeshc,Hot Water a e-2 of 2
Site Address:._` Enforcement Agency: Permit Number:
3. Central Water Heating in Buildings with Multiple Dwelling Units(required for prescriptive)
TO COMPLY-ALL BOXES MUST BE CHECKED
❑, All hot water'piping in main circulatingloop is insulated to requirements of§1500)
❑ Central hot water systems serving six or fewer dwelling units which have(1)less than 25'of distribution piping
outdoors;(2)zero distribution piping underground;(3)no recirculation pump;and(4)insulation on distribution
piping that meets the requirements of Section 1500)
❑ Central hot water systems serving more than 6 dwelling units-presence of either a time control or a
time/temperature control
DECLARATION STATEMENT
• I certify under penalty of perjury,under the laws of the State of California,the information provided on this form is true and correct.
• 1 am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction,or an authorized,
representative of the person responsible for construction(responsible person).
• I certify that the installed features,materials,components,or manufactured devices identified on this certificate(the installation)
conforms to all applicable codes and regulations,and the installation is consistent with the plans,and specifications approved by the
enforcement agency.
• I reviewed a copy of the Certificate of Compliance(CF-1R)form approved by the..enforcement agency that identifies the specific
requirements for the installation. I certify that the requirements detailed on'the CF-lR that apply to the installation have been met.
• I will ensure that a completed,signed copy of this Installation Certificate shall be posted,or made available with the building
permit(s)issued for the building,and made available to the enforcement agency for all applicable inspections. I understand
that a signed,copy of this Installation;Certificate`is required to be included with the documentation the builder provides to
the building owner at occupancy.
Company Name: (Installing Subcontractor or General Contractor or Builder/Owner)
Responsible Person' arae:` sic Responsible Person's
V
c
CS-LB License: Date Signed: Position With Company(Title):
2008 Residential Compliance Forms August 2009
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTIRI0 (408)777-3228•FAX(408)777-3333•buildinaCaD-cupertino.orp
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS APN BP#
OWNER NAME OWNER ADDRESS
�K
DESCRIPTION OF WORK: l�'w
We.are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision,signed,and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
4 41. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner—
Builder"building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. 1, as an Owner-Builder,may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
T G2. I understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
S X63. 1 understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I'may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
S 4-4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
S°G5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars($500), including labor and materials, I may be
considered_an"employer" under state and federal law.
f .C6. I understand if I am considered an"employer" under state and federal law, I must register with the state and
federal government,withhold payroll taxes, provide workers'compensation disability insurance, and contribute to
unemployment compensation for each"employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
y X-7. I understand under California Contractors' State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
s.C8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04/14/10
4.e-9. 1 understand l.may obtain more information regarding my obligations as an"employer"from the Internal
Revenue Service,the United States Small Business Administration,the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB(2752)or www.cslb.ca.gov for more information about licensed
contractors.
X10. 1 am aware.of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
G��11. 1 agree that;as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner-Builders as well as employers.
S-G12. I,agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the.
information I have provided on.this form.Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not-have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you hi
assist as a result of a complaint.Your only remedy against unlicensed
Contractors may be-in'civil-court. it is also important for you to understand that if an unlicensed Contractor or
employee of that individual or,firm is injured while working on your property,you may be held liable for damages. If
you obtain a permitas Owner-Builder and wish to hire Contractors,you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers'compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.).
Lender Name: Lender Address:
Before a building permit can be issued,this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the property owners driver's license,
form notarization, or other verification acce le to the city may be required to be presented when the permit is issued
to verifythe property owner's si nature.
Property Owner's Signator!'' Date: �3
------------- --- -----------------------------------------------------------------------------------------------------------------
(NOTE: The- -fo-llowing Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION-OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner,the execution of which I understand is my personal responsibility, I hereby.
authorize the following person(s).to act as my agent(s)to apply for', sign, and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify,its accuracy.Note:A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city maybe required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
OwnerBuilderForm 2010.doc revised 04/14/10
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino,CA 95014-3255
Telephone: 408-777-3228
C U P E RT 1 N O Fax: 408-777-3333
CONTRACTOR/SUBCONTRACTOR LISfi
41
JOB ADDRESS: to 4PERMIT# {�
OWNER'S NAME: dC PHONE#
GENERAL CONTRACTOR: BUSINESS'LICEN..SE#
ADDRESS: 7 S CITY/ZIPCODE:" s
*Our municipal code requires all businesses working hr the.cityto have a City of Cup "b business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WILL BE KJHDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAIN"qTY OF CUPERTINO
BUSINESS LICENSE. 100,
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information..
SUBCONTRACTOR BUSINE"SS NAME B, TSINESS 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
Sheet Rock
Tile
Owner/Contractor Signature Date