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11030055I CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 11901 PLACER SPRING CT I CONTRACTOR: WATER HEATERS ONLY PERMIT NO: 11030055 OWNER'S NAME: MATSUBARA M AND TOMOKO 1970 E MAIN ST I DATE ISSUED: 03/11/2011 0","INER'S PHONE: 4082550695 V LICENSED CONTRACTOR'S DECLARATION License Class (' 3 (� Lic. # 3-7N573 Contractors of t f 01A(t../ Date 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. 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 permit is issued. APPLICANT CERTIFICATION 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 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 with all no point source regulations per the Cupertino Municipal Code, Section 9.18. Signature �'� `v Date OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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. 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 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 become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, +s, and expenses which may accrue against said City in consequence of the ting of this permit. Additionally, the applicant understands and will comply wadi all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date GRASS VALLEY, CA 95945 PHONE NO: (800)835-5946 BUILDING PERMIT INFO: BLDG ELECT PLUMB r MECH r- RESIDENTIAL r— COMMERCIAL I— JOB DESCRIPTION: REPLACE WATER HEATER, SAME LOCATION, 1ST FLOOR Sq. Ft Floor Area: I Valuation: $1700 APN Number: 36655012.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Date: RE -ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(x) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I wi!I maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Ovyngr pr ar horized agF 3-114 �� Date: CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CITY OF CUPERTINO 6 ITEMS OF 11 PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 36655012.00 DATE ISSUED.......: 03/11/2011 RECEIPT #.........: BS000012881 REFERENCE ID # ...: 11030055 SITE ADDRESS .....: 11901 PLACER SPRING CT SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OWNER MATSUBARA M AND TOMOKO ADDRESS ..........: 11901 PLACER SPRING CT CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: IE INC CONTRACTOR .......: MCGEE, PAT LIC # 18986 COMPANY ..........: WATER HEATERS ONLY ADDRESS ..........: 970 E MAIN ST CITY/STATE/ZIP ...: GRASS VALLEY, CA 95945 TELEPHONE ........: (800)835-5946 OPERATOR: TraciC COPY # : 1 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL ---------- 1BCBSC ------------- VALUATION ---------- 1,700.00 ---------- 1.00 ---------- 0.00 ---------- 1.00 ---------- 0.00 1BSEISMICR VALUATION 1,700.00 0.50 0.00 0.50 0.00 1BUSLIC FLAT RATE 1.00 115.00 0.00 115.00 0.00 1PPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1PRWHEATR UNITS 1.00 25.00 0.00 25.00 0.00 1TRAVDOC FLAT RATE 1.00 42.00 0.00 42.00 0.00 TOTAL PERMIT ---------- 225.50 ---------- 0.00 ---------- 225.50 ---------- 0.00 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT AMOUNT --------------- 336.00 --------------- 336.00 REFERENCE NUMBER -------------------- 7549 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 518 WATER HEATER CbTY OF CUPERTINO CITY OF CUPERTINO FURNACE/AC PERMIT APPLICATION FORM APN # 3 S v 1 Z Date: BIlding Addres�ss: � ol Nl _N Owner's Name: Mofo uki �'�a�5uh r� Phone #: � -15S - Contractor: btA Lx, Phone #: 30 ;2-7 L-/ - 300 Fax #: Contractor License #: Cupertino Business License #: 3-7yS7 3 Contact: Phone #: Fax #: Building Permit Info: Elect Plumb Mech Residential M Commercial Job Description: P,o (ac -e- Cj &J f ly a�s ,r Rt eA Q4'^_ For Residential Installations: Attic ❑ I,' floor Dg 2"a floor ❑ Adhere to minimum setback requirementEl For Commercial Installations: ❑ Replacement same weight ❑ Additional weight (structural calcs) Structural Calculations required for new installation ❑ New installation Planning Approval Required ❑ Cost of Project: Type of Construction (Usage Class): -1 oc3 . ac) Strapped On Platform V1 Bonded New Location Replacement Project Size: Express ❑ Standard ® Large ❑ Major ❑ Valuation: l-7aU,00 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. Revised OV07/vy CITY OF CUPERTINO P -m -N7 FFF ESTIMATOR — BUILDING DIVISION imADDRESS: 4#901 placer spring ct. DATE: 03/11/2011 REVIEWED BY: bobs. UNITS APN: P#: "VALUATION: 1$1,700 PERMIT TYPE: Plumbing Permit 1 PRWHEATR PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: # PENTAMATION PRWHEATR PERMIT TYPE: WORK replace water heater 1st floor. SCOPE APPLIANCE / EQUIP TYPE FEE ID QTY/FEE QTY UNITS BP FEES Water Heater 1 PRWHEATR 1 # $25 PME Unit Fee: $25.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes No $0.00 TOTALS: Travel Documentation Fee: I TRA VDOC $25.001 Strong Motion Fee: IBSEISMCR lVf)TF- Thava fooc oro hiycod n" tho nrolimi"any i"farmatin" availahlo and aro n"Iv tin P.0imato- Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 09-051 Iff, 7/1/10) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $25.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes No $0.00 Travel Documentation Fee: I TRA VDOC $42.00 Strong Motion Fee: IBSEISMCR $0.50 Select an Administrative Item Bldg, Stds Commission Fee: IBCBSC $1.00 I SUBTOTALS: 1 $110.501 $0.001 TOTAL FEE: $110.50 Revised: 01/15/2011 Prescriptive Certificate of Compliance: Residential CF -IR -ALT Residential Alterations WATER HEATER e 1 of 1 Project Name- A, ksicbarCA- 4,GiAIwc"C)- General Information Climate Zone # 12 # of Stories Site Address: t I U, %6e r 6Lrit+ Enforcement Agency: Date: Building Type V Single Family ❑ Muhi Family Water Heater Type/Fuel Circle the Front Orientation: N, E, S, W, or degrees Conditioned Floor Ater (CFA): Tank Project Type: ❑ Alterations E3 Envelope ❑ Fenestration ❑ Roof ❑ HVAC lacement or a Out ❑ Dud Replacement ❑ Water Heater WATER HEATING List water heaters and boilers for both domestic hot water (DHIV) heaters and hyctronic space heating. Individual dwelling DHRR heaters must be gas or propane fired, and may not exceed 50 gallons. Hot water pipe insulation from the DHR' heater to the btdten(s) and on all underground hot water pipes is required in all com Hentpackages in all climate zones. External Tank Water Heater Type/Fuel Distribution Type Number In Tank Energy Factor or Insulation Type' (Standard, Recirculating)2 System Capacity (gal) Tbermal Efficiency R -Value' hAwl ( Ct 5 Gt r GL 1 U , S 1 Z 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 the installation of a recirculating water heating system for single dwelling units. 3. The external water heating tank and pipes shall be insulated to meet the requirements of §I50(j). Documentation Author's Declaration Statement • I certify that this Certificate of Compliance documentation is accurate and compktr- Name: . Signature: 5nZLL11Q Company: ate,, Hen -e- a1/1 enc,: � : Z" --o-0 Ate:If n 9 -70 EA St fflAifl 5 tle-e t Applicable ❑ CEA or 13CEPE (Certification #): City/StatelZip:Phone: a(-u!�,S Vali c CCA? C rq`(6- 5 3d' t;Z 71/-3001 Responsible Building Designer's Declaration Statement • I an eligible under Division 3 of the California Business and Professions Code to accept responsibility for the building design identified on this Certificate of Compliance. • I certify that the energy features and performance specifications for the building design identified on this Certificate of Compliance conform to the requirements of Title 24, Parts 1 and 6 of the California Code of Regulations. • The building design features identified on this Certificate of Compliance are consistent with the information provided to document this building design on the other applicable compliance forms, worksheets, calculations, plans and specifications submitted to the enforcement agency for approval with this building it application. Name: M C& 116 3 l�e�o k s Signature: -A-Q Company:Date _ Address: -70 EASt .4o Srreet aavU License: 37�{5�3 City/State/Lipista1 S S UCS. I I E C F? o�lY6 Phone. 30- a7` -3001 For assistance or questions regarding the Energy 3tarrdards, contact the Energy Hotline at: 1-800- 772-3300. Registration Number: Registration DatelTime: HERS Provider. 2008 Residential Compliance Forms February 2010 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: `�J t Q�I t 6 Ma S Bala PERMIT # OWNER'SNAME: jjq0j lvc-e 9 /'fes orf- PHONE# 0 L5S<GCoRS GENERAL CONTRACTOR: Uj6Ur P&%/5 0 1 BUSINESS LICENSE # ADDRESS: C{.1�1 �v((��yt 5 CITY/ZIPCODE: f-0 *Our municipal code requires all businesses working in the city to have a City of Cupertino business ncense. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND AL}. SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Please check applicable subcontractors and complete the following information: Date Owner / Contractor Signature Date 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 Sheet Rock Tile Owner / Contractor Signature Date