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09080395 CITY OF CUPERTI NO BUILDING PERMIT BUILDING ADDRESS: 21909 DOLORES AVE CONTRACTOR:WATER HEATERS ONLY PERMIT NO:09080395 OWNER'S NAME: RAYMOND WONG 970 E MAIN ST DATE ISSUED:08/28/2009 1ER'S PHONE: 4088732769 GRASS VALLEY,CA 95945 PHONE NO:(800)835-5946 ❑ LICENSED CONTRACTOR'S DECLARATION 3 � BUILDING PERMIT INFO: BLDG f— ELECTF PLUMB � License Class C Lic.# 3 14 15 '7 3 &0'7 � MECH r RESIDENTIAL f— COMMERCIALContractor Date_q/_�A � I hereby affir that m li ensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE EXT WATER HEATER,STRAPPED&ON (commencing with Section 7000)of Division 3 of the Business&Professions PLATFORM 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. 1 have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$990 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:35714070.00 Occupancy Type: APPLICANT CERTIFICATION I certify that 1 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. 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 non-point source regulati s per the Cupertino Municipal Code,Section Issued b ! 9.18. ,�` Date: �e—'F Signature Ye " 2q 4� RE-ROOFS: �- OWNER-BUILDER DECLARATION 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 hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: 1 have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the i ompliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. :safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by 2kdditionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this (ontaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall llealth&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Owne or autho ' en : Compensation laws of California. If,after making this certificate of exemption,I _ ate:_i/2 become subject to the Worker's Compensation provisions of the Labor Code,I must rth / forthwith comply with such provisions or this permit shall be deemed revoked. C RUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) 1 certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save unify and keep harmless the City of Cupertino against liabilities,judgments, ,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date 0102 03q CITY OF CUPERTINO WATER HEATER CU 'ERTINO PERMIT APPLICATION FORM APN # Date: *o-7 g1k r, Building Address: L,? I 2 O q Do/ry sAke • n o Owner's Name: Phone #: (�M X 7-? �� 76 1k111671tUnM-JContracto : 6111 Phone #:(J�0 a 7t/_3W/ X�?60 GC S (7 7 Fax #: S � Cupertino Business License #: Contractor St e License #: �l31 /l0 � �� x" 73 Contact: Phone �7C/- 3C,01 C(� X ZvU Fax #: Fol) Building Permit In Bldg Elect Q' Plumb 0` Mech Residential ET�Commercial ❑ Solar ❑ If solar, number of kilowatts: Strapped On Platform Bonded ❑ New Location ❑ Replacement Valuation (cost of project): : q10 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 08/20/09 CITY OF CUPERTINO WATER HEATER C�UPERTIl+ O PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Permit Type Group 1PCWHEATR Commercial Water B PCWHEATR HeaterNent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commissio ri Fee 1BSEISMICOM Seismic Commercial B / 1 PRWHEATR Residential Water B PRWHEATR HeaterNen. 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICRE Seismic Residential B 1 PPERMITFEE Plumbing P-Irmit P IT AVDOC Travel & B Documental ion 1BUSLIC Business Li,-,ense B M.Indoor Air Quality and Finishes INPUT Rescurces Energy IA-DiHealth 1.Use Lawtdo-VOC Paint 1 IAQ/Health pts y=yes 0 2.Use Low VOC,Water-Based Wood Finishes 2 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 61AQ/Health pts y=yes p 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0 7.Seal au E2Wosed.Partioleboaa d or MDF 4 IAQ/Health, pts y=yes 0 S.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 ! N.Flooring 1 1 1.Select FSC Certified Wood Flooring B 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 5 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 p . 1 1 1 Total Points Avallable: 1401 1307-----571 Total Points Project Received: 1 01 01 0 G:datalprogs/gree ibuildingguidelines/remodelers/greenpointsfina12.12.04protected.xls Community Development 10300 Torre Avenue a Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 ,;UPEkTINO Building Department JOB ADDRESS- PERMIT # o t o Q a t 2I C/O Cl �o 10 r?-- A/C OWNER'S NAME: - o vJ PHONE # C 5 30 j 2-7 q - 3 Oo 1 GENERAL CONTRACTOR: s v,,)1v FAX # 653v 2-7 4 - o ri h I am not using any subcontractors: a Date Please check applicable subcontractors and cora ete the followin 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