10080106 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21060 WHITE FIR CT CONT'3ACTOR:WATER HEATERS ONLY PERMIT NO: 10080106
970 E T4AIN ST DATE ISSUED:08/16/2010
OWNER'S NAME: JAY AOUVVURE
GRAS:;VALLEY,CA 95945 PHONE NO:(800)835-5946
BIER'S PHONE: 4082550464
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB r
License Class C `� Lic.# 2-7 q -(p73 MECH r RESIDENTIAL r COMMERCIAL r
Contractor JA) tat kej .5 Oh t/ Date b
JOB DESCRIPTION:REPLACE 40 GAL
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. Sq,FI Floor Area: Valuation:$1100
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 whichthis APN Vumber:35905108.00 Occupancy Type:
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 p ERMIT EXPIRES IF WORK IS NOT STARTED
to building constriction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 80 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 regulations per the Cupertino Municipal Code,Section Issucd bye� � Date:
9.18.
Signature Date
RE-ROOFS.
OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
`-' insta led without first obtaining an inspection,I agree to remove all new materials for
I 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, Sign eture of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044, —
Business&Professions Code) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code).
HAZARDOUS MATERIALS DISCLOSURE
I hereby affirm under penalty of perjury one of the following three
declarations: I ha ve 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 compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safe ty Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Adc itionally,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 con:aminants as defined by the Bay Area Air Quality Management District I will
mai ntain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Hes lth&Safety Code,Sections 25505,25533,and 25534.
1 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 0!/w per or uthoragent:
Compensation laws of California. If,after making this certificate of exemption,I Date:
becorie 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. CONSTRUCTION LENDING AGENCY
I he reby 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.)
I certify that I have read this application and state that the above information is Lei ider'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 Lei uder's Address
upon the above mentioned property for inspection purposes.(We)agree to save
'emnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
s,and expenses which may accrue against said City in consequence of the
6,anting of this permit.Additionally,the applicant understands and will comply I u uderstand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
Lb:ensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 35905108 . 00
DATE ISSUED. . . . . . . : 08/16/2010
RECEIPT #. . . . . . . . . : BS000011194
REFERENCE ID # . . . : 10080106
SITE ADDRESS . . . . . : 21060 WHITE FIR CT
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER JAY ACUVVURE
ADDRESS 21060 WHITE FIR 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
FEE ID UNIT QUANTITY AMOCNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 1, 100 . 00 1 .00 0.00 1 . 00 0. 00
1BSEISMICR VALUATION 1, 100. 00 0 .50 0 .00 0 .50 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 110 .50 0 .00 110 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- -- ------------------
CHECK 110 .50 #9295
---------------
TOTAL RECEIPT 110 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER
CITY OF CU.PERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: UATE: REVIEWED BY:
APN: BP#: "VALUATION: $1,100
;*PEIRMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY TO7,gL APPLICATION 1 RPWH
USE: SFD or Duplex T`�,00H .lRk",i; TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY BP FEES
Water Heater 1BPWHEAT 1 $25
TOTALS: $25.00
If,'h Pluri c71, Plumb.Plan Check D.0 hrs $0.00 t.iec'_ i'lan Ctac
L9,>ctt Y ;r,rir F'e , Plumb.Permit Fee: 1PPERMITE3
I;Ir r Pe,rru J
},,r,, t�rth trerr Other Plumb Insp. 0.0 hrs $42.00 orf
I'%Imb, /n p, I �: 1"-ic( fnvs 1"v'
NOTE. Theseees are based on the relimina in ormation avail able and are onlyan estimate. Contact the De ptfor addn'1 info.
FEE ITEMS (Fee Resolution 09-051 Ef'. 7/1/IOj FEE QTY/FEE MISC ITEMS
flirt C'hccl
Strp1r1. Pt'
PME Plan Check: $0.00
1'er'lnit
Fcc: - T
Sr,i1/,1 hl'.p 1'(v
PME Unit Fee: $25.00
PME Permit Fee: $42.00
C_t?l;Sll`t?�`I1fJPt 7"n
�i c�tt.rrlcctl rw�lFcc:
Work Without Permit? 0 Yes 0 No $0.0C
Plc:rrrnirr<� 1'crc.�:
I rol cl 1)oUtnr7(1Wc 1hm /ee"c '_
S11-ons; -k1wim] Fcc: Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $68.00 $0.00 TOTAL FEE:. $68.00
Revised: 8/12/2010
CITY OF CUPERTINO
WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN# ,., �.f Date: _ ke
' (
Building Address:
Owner's Name: Phone #:
,4Q f� OU VVLk/`e-
1/09 - 7-5s-- oy(av
Contractor: Phone #:
j D Z 7 r-1 1 3W l
Fax #:
Cupertino Business License #: Contractor State License #:
31857 .5
Contact: nPhone #:
�u0 1- ,!)- '74
w`
�x�'�� pFax #:
Building Permit Info:
Bldg Elect Plu nb ] Mech
Residential D Commercial ❑
Job Description:
Strapped ❑ On Platform ❑ Bonded ❑ New Location ❑ Replacement �]
Valuation (cost of project): 1100100
Project Size: Express ❑ Standard F1 Lame ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to
the application or if applicable, i aclude in plan set & the sheet index.
Green Building Points achieved:
Revised 03/10/10
INPUT Fir-scurms Energy IAD7Heafth
M.lndDDr Air Quality and Finishes
1.Use LowMo-VOC Paint 1 IAO/Health pts y=yes 0
2.Use Low VOID,Water-Based Wood Finishes 2 IAO/Health pts y=yes 0
3.Use Low/No VOC Adhesives 3 IAC YHealth pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Re Source pts y=yes D
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61ACVHealth pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IACdHealth pts y=yes 0
7.Seal all EqmW flarrtioleboard or MDF 4 IAC OHealth. pts y=yes 0
B.Use FSC Certified Materials for Interior Finish 4 Re source pts y=yes D
9.Use Finger-Jointed or Recycled-Content Trim 1 Re source pts y—yes 0
1 D.Install Whole House Vacuum System 3 IAO]Health pts y=yes 0
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring 8 Resource pts y=yes D
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 p
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 0
1 ! 1
Total Points Available: 1 1401 130E----5-71
Total Points Project Received: �—j 01 0
/q,
G:datalprogs/greenbuildin[guidelines/remodelerslgreenpointsfinal2.12 34protected.x1s
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: 02 0 �i C,2, FI f' �t PERMIT# � l
OWNER'S NAME: -TGZ AOU PHONE
GENERAL CONTRACTOR: aK I BUSINESS LICENSE# 37�s73 _
ADDRESS: 0?D � y0a)N '3T #260 CITY/ZIPCODE: 55 Colla
*Our municipal code requires all businesses working in the ,-ity 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: Date
Signature
Please check applicable subcontractors and complete t he following information:
j/ 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