10030160 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21765 COLLINGSWORTH ST CONTRACTOR:AAA FURNACE&AIR PERMIT NO: 10030160
CONDITIONING
"NER'S NAME: WARD PEARL H TRUSTEE 1712 STONE AVE DATE ISSUED:03/29/2010
OWNER'S PHONE: 4082524473 SAN JOSE,CA 95125 PHONE NO:(408)293-4717
❑ n LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r- PLUMB
License Class C`7 C 1 c Lic.# 7(O�S s 7 / MECH r- RESIDENTIAL r COMMERCIAL
Contractor A 1�/:�t(r" C2- Date
JOB DESCRIPTION:REPLACE EXISTING WATER HEATER
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.Ft 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 which this
APN Number:35617069.00 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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,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, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may true against said City in consequence of the
granting of this permit. d i iohally,the applicant understands and will comply
with all - oint rce eg6lations per the Cupertino Municipal Code,Section Issued by: Date:9--2a l v
9.18.
S; -ature Date
RE-ROOFS:
v❑ 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
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, 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: I 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 compliance 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 Additionally,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 contaminants as defined b he Bay Area Air Quality Management District I will
maintain compl' cc tCupertino Municipal Code,Chapter 9.12 and the
permit is issued. Heal &S etyC C'S ions 25505,25533,and 25534.
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 'Own •or o ' ed agent: _ 2 g
Compensation laws of California. If,after making this certificate of exemption,I Date:
become 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 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.)
I 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
the above mentioned property for inspection purposes.(We)agree to save
.inify and keep harmless the City of-Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may ac e a inst said City in consequence of the
granting of this permit.Additi ally, a applicant understands and will comply I understand my plans shall be used as public records.
with all non-point so e r ulat' s per the Cupertino Municipal Code,Section
9.18. -7 Licensed Professional
Signature Date
CITY OF CUPERTINO
5 ITEMS OF 12 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 35617069. 00
DATE ISSUED. . . . . . . : 03/29/2010
RECEIPT # . . . . . . . . - : BS000010045
REFERENCE ID # . . . : 10030160
SITE ADDRESS 21765 COL'LINGSWORTH ST
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER WARD PEARL H TRUSTEE
ADDRESS 21765 COLLINGSWORTH ST
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4708
RECEIVED FROM AAA FURNACE & AIR C
CONTRACTOR RANDO, JIM LIC # 8050
COMPANY AAA FURNACE & AIR CONDITIONING
ADDRESS 1712 STONE AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE (408) 293-4717
FEE ID UNIT QUANTITY AMOUNT 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
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------
518 WATER HEATER
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
CUPERTINO
APN # Date.
Building Address: Oq 11 co S- C Q , n G S W oy-O S tf-e e,(-
Owner's Name: P <-,C r t, "-?Q,I-d Phone 7,3
Contractor: CQ Phone #: z4gg -CRq,3--q
Fax #: 4-69 -e;2S34 ?7/
Cupertino Business License M Contractor State License #:
Ito 88'-7 /
Contact: C-pr 22 J ze,, Phone #:ef48- a93 4/>/
Fax #: 1-165- ,5;79-5 - & > -7 ,/
Building Permit Info:
Bld ❑ Elect ❑� Plumb Mech ET- —
Residential 2/ Commercial ❑ Solar ❑ If solar, number of kilowatts:
Strapped ❑ On Platform ❑ Bonded New Location ❑ Replacement E -
Valuation (cost of project):
Project Size: Express Standard ❑ Large ❑ Major 0
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
IM WATER HEATER
PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Permit Type
Group
1 PCWHEATR Commercial Water B PCVkHEATR
HeaterNent
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fee
1BSEISMICOM Seismic Commercial B
1 PRWHEATR Residential Water B PRWHEATR
HeaterNent
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fee
/ 1BSEISMICRE Seismic Residential B
1PPERMITFEE Plumbing Permit P
1 TRAVDOC Travel & B
Documentation
1 BUSLIC Business License B
M.Indoor Air Quality and Finishes
1.Use Lo~Oc Pain## 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 YAG Adhesim 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
0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes
7.Seal>Mfxposodf wWaboandar#1DF 41AQ/Health. pts y=yes 0
B.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
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring 8 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 0
1 i 1
Total Points Available: 1 1401 1301---
30 57
Total Points Project Received: 1 9k73
0 0
-/ 6 —/ 0
G:data/progs/greenbuildingguidelines/remodelers/greenpointsfinal2.12.D4protected.xis
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
CITY OF
'UPEkTINO
Buini De artment
JOB ADDRESS: PERMIT #
of I `7 b�' C v l I ,►� �cc�cr��
OWNER'S NAME: a r� tsar-c� PHONE # !.�0� - �9 3-u ��7
GENERAL CONTRACTOR: I-U v�•�4 FAX# - 3 " /
I am not using any subcontractors: Date
Signature
Please check a licable 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 Ro
T' e
�C)
Owner/Contractor gnature Date