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09080029 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: l 107 HOLLYHEAD LN CONTRACTOW AMERICAN PLUMBING& PERMIT NO:09080029 DRi SIN C`"F,R'S NAME: ANTE SHAUT 446:1 HOLLOW GATE LN DATE ISSUED:08/06/2009 SAri JOSE,CA 95127 PHONE NO:(408)205-0506 OvT,-iER'S PHONE: 4082684 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class l.. Lia# l` ® 1 MECH r— RESIDENTIAL f— COMMERCIAL Contractor `Q tJ� \H� 8` (ws Date o eq JOB DESCRIPTION:WATER HEATER REPLACEMENT 1 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 Sq. Ft Floor Area: Valuation:$700 performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as provided for by APN Number:36226013.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED correct.1 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 FROM 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 'r'-----� Date: granting of this perm . Additionally,,the applicant understands and will comply Issued by: ^ with all non-points rce regulati per the Cupertino Municipal Code,Section 9.18. - r _ Rs •iure Date RE-ROOFS: A I roofs shall be inspected prior to any roofing material being installed. If a roof is ❑ OWNER-BUILDER DECLARATION in stalled without first obtaining an inspection,1 agree to remove all new materials for in;pection. I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: _ Date: the following two reasons: 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, ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE hereby affirm under penalty of perjury one of the following three I have read the hazardous materials requirements under Chapter 6.95 of the (alifornia Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain declarations: c)m liance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain a Certificate of Consent to self-insure for Worker's Safety Code,Section 25532(a)should I store or handle hazardous material. Compensation,as provided for by Section 3700 of the Labor Code,for the A dditionally,should I use equipment or devices which emit hazardous air performance of the work for which this permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I have and will maintain Worker's Compensation Insurance,as provided for by maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Section 3700 of the Labor Code,for the performance of the work for which this I lealth&Safety Code,Sections 25505, and 25534. permit is issued. 1 certify that in the performance of the work for which this permit is issued,I shall Owner or uthoriz d age Date: O 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,1 become subject to the Worker's Compensation provisions of the Labor Code,I mustV0bbly CONSTRUCTION LENDING AGENCY forthwith comply with such provisions or this permit shall be deemed revoked. Firm that there is a construction lending agency for the performance of work's for which this permit is issued(Sec.3097,Civ C.) APPLICANT CERTIFICATION Lender's Name I certify that 1 have read this application and state that the above information is ,ender's Address 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 be above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION ';. ,ni y and keep harmless the City of Cupertino against liabilities,judgments, understand m plans shall be used as public records. costs,and expenses which may accrue against said City in consequence of the y 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 __ CITY OF CUPERTINO WATER HEATER CUPEI�TINO PERMIT APPLICATION FORM APN # �! 06 Date: Building Address: Owner's Name: Phone #: Contractor: Phone � .�n.�i �� SVT' RT-\e5;�\.\CAr\ �"�j � �` Fax #: Cupertino Business License #: Contractor State License #: c�-7 �7 -�.\ I o I Contact: Phone #: � -t> O S O Fax #: Building Permit Info: Bldg []' Elect [�/� Plumb Mech ❑-^ Residential Commercial ❑ Job Description: "— "v C� Strapped ❑ On Platform — Bonded E]-�ew Location ❑ Replacement Valuation (cost of project): ,-700- (-:0 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 01/07/09 CITY OF CUPERTINO } '+ WATER :HEATER CUCITS T Y 1NO PERMIT. APPLICATION FORM R. Quantity Fee ID Fee Descripti,:)n Fee Permit Type Grou 1PCWHEATR Commercial Water B PCWHEATR Heater/Vent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission 1,ee 1BSEISMICOM Seismic Convnercial B 1 PRWHEATR Residential )A ater B PRWHEATR Heater/Vent r 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES f Commission Fee 1BSEISMICRE Seismic Residential B 1PPERMITFEE Plumbing Permit P 1 TRAVDOC Travel & B Documentati:)n 1 BUSLIC Business Lic,nse B INPUT Res[)UTCeS EnerMr IAD/Health M.Indoor Air Quality and Finishes 1.Use Low/No-VOC Paint 1 IAQ/Health pts y=yes 0 2.Use Low VOC,Water-Based Wood Finishes i 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 0 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0 7.Seal all Exposed Particleboard or MDF 4 IAQ/Health. pts y=yes 0 3.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 01 1 10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 1 0 . 1 1 1 N.Flooring 1.Select FSC Certified Wood Flooring 3 Resource pts y=yes 0 2.Use Rapidly Renewable Flooring Materials t Resource pts y=yes 0 3.Use Recycled Content Ceramic Tiles I 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 1 Resource pts y=yes 0 6.Install Recycled Content Carpet with Low VOCs 1 Resource pts y=yes 0 Total Points Available: 140 130 57 Total Points Project Received:1 0 01 0 G:data/progs/gre anbuildingguidelines/remodelers/greenpointsfinal2.12.D4pmtected.xis Community Development 10300 Torre Avenue , Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 CITY OF 'UPERTINO Building De artment JOB ADDRESS: PERMITTj#�,0�� \k o`a}. OWNER'S NAME: 1,� S- c/' PHONE # GENERAL CONTRACTOR: FAX # I am not using any subcontractors: ignaa ture — Date Please check applicable subcontractors and complete 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 er/Contractor Signature Date