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10100200CITY OF CUPERTI BUILDING ADDRESS: 795 ALDERBROOK LN OWNER'S NAME: PAUL & GRACE ROBINSON ✓NER'S PHONE: 4083919161 LICENSED CONTRACTOR'S DECLARATION License Class Lic. # cep QJ (p r �� RE PAR -am VA I herebfaffirm 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. NO BUILDING PERMIT 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 relatin ; 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 non -point source regulations per the Cupertino Municipal Code, Section 9.18. ❑ OWNER- BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one (f the following two reasons: I, as owner of the property, or my employees with wages as their sole compensatiol1, will do the work, and the structure is not intended or offered for sale (See. 7044, Business & Professions Code) 1, 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 mu: t 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 i the above mentioned property for inspection purposes. (We) agree to save ,mnify 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 non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date CONTRACTOR: ONE DAY I PERMIT NO: 10100200 COMPLETE REPIPE 658 N 14TH ST DATE ISSUED: 10/28/2010 SAN JOSE, CA 95112 1 PHONE NO: (408) 903 -8184 BUILDING PERMIT INFO: BLDG ELECT PLUMB MECH RESIDENTIAL COMMERCIAL JOB DESCRIPTION: REPLACE 50 GALLON WATER HEATER, COPPER REPIPE THROUGH OUT Sq. Ft Floor Area: I Valuation: $4000 APN Number: 36916013.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued b y Date: F 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. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) 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 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: 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 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: PERMIT # OWNER'S NAME: ► v-\, PHONE # 3 GENERAL CONTRACTOR C , BUSINESS LICENSE # ADDRESS: L !1 CITY /ZIPCODE: *Our municipal code requires all businesses working it 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 SUBCONTVACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. _ 4_0 I am not using any subcontractors. „ii, ature Date Please check applicable sub retractors and complete the following information: 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 6 ITEMS OF 6 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk.: Lot: APN ......... 36S16013.00 DATE ISSUED.......: 10/28/2010 RECEIPT # ......... BSC00011862 REFERENCE ID # ...: 10100200 SITE ADDRESS .....: 79E ALDERBROOK LN SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ...... OWNER PAUL & GRACE ROBINSON ADDRESS ..........: 79_ ALDERBROOK LN CITY /STATE /ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM CONTRACTOR ... COMPANY ...... ADDRESS ...... CITY /STATE /ZIP TELEPHONE .... OPERATOR: SylviaM COPY # : 1 JOSE MENDEZ JOSE LUIS MENDEZ LIC # 32132 ONE DAY COMPLETE REPIPE 65f' N 14TH ST SAI JOSE, CA 95112 (408) 903 -8184 FEE ID UNIT QUANTITY liMOUNT 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 1PPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1PREPPIPE 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 -- --- - - - - -- 152.50 ---- - - - - -- 0.00 ---- 152.50 0.00 METHOD OF PAYMENT --------------- -- CASH TOTAL RECEIPT : AMOUNT --------------- 152.50 --------------- 152.50 REFERENCE NUMBER --------------- - - - -- CASH VOICE ID DESCRIPTION VOICE ID DESCRIPTION -- - - - - -- ---------------------- - - - - -- -- - - - - -- ---------------------- - - - - -- 518 WATER HEATER 1. Use Low/No -VOC Paint 1 IAQ/Health pts y =yes 2. Use Low VOC, Water -Based Wood Finishes 2 IAQ/Health pts y =yes 3. Use Low/No VOC Adhesives 3 IAQ/Health pts y=yes 4. Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 5. Use Engineered Sheet Goods with no added Urea 4 Resource pts y =yes Formaldehyde 61AQ/Health pts y =yes 6. Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y =yes 7. Seal al E*med Particleboard cx MY 4 IAQ/Health. pts y =yes B. Use FSC Certified Materials for Interior Finish 4 Resource pts y =yes 9. Use Finger- Jointed or Recycled- Content Trim 1 Resource pts y =yes 10. Install Whole House Vacuum System 3 IAQ/Health pts y =yes N. Flooring 1. Select FSC Certified Wood Flooring B Resource pts y =yes 2. Use Rapidly Renewable Owring Materials 4 Resource pts y =yes 3. Use Recycled Content Ceramic Tiles 4 Resource pts y =yes 4. Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y =yes 5. Use Exposed Concrete as Finished Floor 4 Resource pts y =yes 6. Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes Total Points Available:. Total Points Project Received: 0 1401 130 57 01 0 0 Mdatalprogs/gn + enbuilcgngguidelinesl remodelers/ greenpointsfinal2 .12.D4proteated.xl s CITY OF CUPEkTINO CITY OF CUPERTINO REPIPE /SEWS R/MAIN SERVICE PERMIT APPLICATION FORM r I • I_A APN # Date: to-2-8-10 Building Add r ss- Permit Type Owner's Name: / Phone #: `� 4z .; L Contractor: Phone #: ,a',2,41 ,3 ef Fax #: P Contact: `� %, (� iD Phone 1PGASCOM Commercial Gas Piping System 1 -4 Outlets Fax #: Contractor License #: 93S 6 9.2 1BCBSC Cupertino Business License #: B Job Description: C � r rc r� �'''i /1 d u � LAA Out ww lip`/ t,�5� 10 A 1, �o M S c�'� � r0 t 4 , --O 1BSEISMICOM Seismic Commercial Residential Commercial ❑ Valuation: Project ize: Express 0 Stand d 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: Quantity Fee ID Fee Description Fee Group Permit Type 1PCSEWER Commercial building sewer /sanitary ;;ewer P 11CPSS 1BPREPIPE Commercial re -pipe per fixture P 1CPRP 1PGASCOM Commercial Gas Piping System 1 -4 Outlets P 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICOM Seismic Commercial P Revised 01/07/09