11010125 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADvRESS: 21592 VILLA MARIA CT CONTRACTOR:AIR QUALITY HEATING& PERMIT NO: 11010125
AIR
n"'NER'S NAME: EILEEN CHEUNG 720 NORTHRUP ST DATE ISSUED:01/24/2011
(r .NER'S PHONE: 4082529027 SAN JOSE,CA 95126 PHONE NO:(408)293-7138
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB
10
License Class Lic.# MECH r RESIDENTIAL r COMMERCIAL
ContractorA AU Date
JOB DESCRIPTION:INSTALL TANKLESS WATER HEATER AT GARAGE
I hereby affirm that I am licensed Ader the provisions of Chapter 9
LOCATION&
(commencing with Section 7000)of Division 3 of the Business&.Professions ADD NEW GAS LINE
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 Sq.Ft Floor Area: Valuation:$4000
permit is issued.
APPLICANT CERTIFICATION APN Number:36638017.00 Occupancy Type:
I certify that I have read this application and state that the above i
at
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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code, ection
9.18. y
Issued
S;-nature Date
❑ WNER-BUILDER DECLARATION RE-ROOFS:
1 hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following-three
declarations: HAZARDOUS MATERIALS DISCLOSURE
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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I Owner or authorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
n the above mentioned property for inspection purposes.(We)agree to save
.unify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
I understand my plans shall be used as public records.
9.18.
Signature Date Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 21592 villa maria ct. DATE: 01/24/2011 REVIEWED BY: bobs.
APN: BP#: *VALUATION: 1$4,000
xPERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY PENTAMATION PRWHEATR
USE: SFD or Duplex PERMIT TYPE:
WORK install tankless water heater at garage location add new gas line.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Heater 1PRWHEATR 1 # $25
Piping, Gas <=4 Outlets 1 PGASRES 1 # $63
TOTALS: $88.00
t.t,".h Phin t`Fig rk Plumb.Plan Check 0.0 hrs $0.00 F=`_ 1'"'m OW"i'`'(
Plumb.Permit Fee: IPPERMIT I;'t.c P<: sr.zt Ftf
C),11rr afc�1,. Irisi>. Other PlumbInsp. 0.0 hrs $42.00 oi/, , '�c_1P,s,�.
Li
Ifs,i',. fav). I co. 1'.`tt;ul, 1;;;1;. F, 1 r'< ItE �. P
NOTE: Theseino.
-fees are based on the preliminaryin ormation available and are onl an estimate. Contact the Dept-for addn'I
FEE ITEMS (Fee Resohetion 09-051 Eff. 7/1!101 FEE QTY/FEE MISC ITEMS
Plan t:hcck I ce:
supp/. 1'C:'F'ce
F-71
PME Plan Check: $0.00
11("'rinit Fee:
Slppl. IHSS)Foe
PME Unit Fee: $88.00
PME Permit Fee: $42.00
C:'Onstruction 7-,LV
,,j,:ousii(,u1
-,L-
,,tcousii(,u1 Rciliew Fec,-
Work Without Permit? 0 Yes E) No $0.00
F'lcarartilts; F�'��c=s.
Travel Documentation Fee: 1T'RAVDOC $42.00
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Std.s Commission Fee: IBCBSC $1.00
SUBTOTALS: $173.50 $0.00 TOTAL FEE: $173.50
Revised: 01/03/2011
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: 1�i4- /f- PERMIT#
OWNER'S NAME: PHONE # Gf-7-�Z Vii,
GENERAL CONTRACTOR: BUSINESS LICENSE#
ADDRESS: �' 0�� CITY/ZIPCODE: �Sr
*Our municipal code requires al businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: AAo�7= /A-zvIll,
Signature Date
Please check applicable subcontractors and complete the following information:
V 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
CITY OF CUPERTINO
6 ITEMS OF 16 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36638017 .00
DATE ISSUED. . . . . . . : 01/24/2011
RECEIPT #. . . . . . . . • : BS000012552
REFERENCE ID # . . . : 11010125
SITE ADDRESS . . . . . : 21592 VILLA MARIA CT
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA
OWNER . . . . . . . . . . . . : EILEEN CHEUNG
ADDRESS . . . . . . . . . . : 21592 VILLA MARIA CT
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : MATTHEW T FARBER
CONTRACTOR . . . . . . . : MATTHEW FARBER LIC # 22791
COMPANY . . . . . . . . . . : AIR QUALITY HEATING & AIR
ADDRESS . . . . . . . . . . : 720 NORTHRUP ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95126
TELEPHONE . . . . . . . . : (408) 293-7138
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- --------
1BCBSC VALUATION 4, 000 . 00 1 . 00 0 .00 1. 00 0 .00
1BSEISMICR VALUATION 4, 000 . 00 0 .50 0 .00 0 . 50 0 .00
1PGASRES OUTLETS 1. 00 63 .00 0 .00 63 . 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 173 .50 0.00 173 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------
CREDIT CARD 596 .70 VISA
---------------
TOTAL RECEIPT 596 .70
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
------ ---------------------------- -----
518 WATER HEATER
f 0/
CITY OF CUPERTINO
x WATER HEATER
CUPEkTiNO PERMIT APPLICATION FORM
APN # Date:
Building Address:
Owner's Name: Phone #:
611C-C-^1 W ? - 7- -cle Z,_;Z_
Contractor: Phone #:
Fax #:
Cupertino Business License #: Contractor State License #:
T6 P V 9�
Contact: Phone #:
A'41T
Fax #:
Building Permit Info:
Bldg ❑ Elect Plumb Mech
Residential Commercial ❑
Job Description: 15:iV 5 nf_t_ - 121" r–t—F37S
StrappedOn Platform ❑ Bonded New Location ❑ Replacement
Valuation (cost of project):
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 03/10/10