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10080016 CITY OF CUPERTINO BUI]--JDING PERMIT UILDING ADDRESS: 10317 MIRA VISTA RD CONTRACTOR:AAA FURNACE&AIR PERMIT NO: 10080016 CONDITIONING "INER'S NAME: DAVID CLOUGH 1712 STOVE AVE DATE ISSUED:08/03/2010 PWNER'S PHONE: 4082530626 SAN JOSL,CA 95125 PHONE NO:(408)2934717 ;' LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB icense Class C?& Lic.# 7A- 8 b7/ r F MECH RESIDENTIAL COMMERCIAL 'ontractor l(Lt CJ V a.0 Date �' " ?�'''��' hereby affirm that I am licensed under the provisions of Chapter 9 JOB DE'CRIPTION:REPLACE WATER HEATER WTIH TANKLESS&INSTALL :ommencing with Section 7000)of Division 3 of the Business&Professions 1 GAS LINE EXTENTION :ode and that my license is in full force and effect. hereby affirm under penalty of perjury one of the following two declarations: have and will maintain a certificate of consent to self-insure for Worker's :ompensation,as provided for by Section 3700 of the Labor Code,for the erformance of the work for which this permit is issued. have and will maintain Worker's Compensation Insurance,as provided for by lection 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Flow Area: Valuation:$4500 ,ermit is issued. APPLICANT CERTIFICATION APN Number:35702039.00 Occupancy Type: certify that I have read this application and state that the above information is orrect.I agree to comply with all city and county ordinances and state laws relating o building construction,and hereby authorize representatives of this city to enter ppon the above mentioned property for inspection purposes. (We)agree to save pEF MIT EXPIRES IF WORK IS NOT STARTED ndemnify and keep harmlesLtheapplicant rtino against liabilities,judgments, osts,and expenses whichsaid City in consequence of the WTCHIN 180 DAYS OF PERMIT ISSUANCE OR ;ranting of this pe dcant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. vith all n sou upertino Municipal Code,SectionIssued lu. � � Date:-natureDate OWNER-BUILDER DECLARATION RE-ROOFS: f hereby affirm that I am exempt from the Contractor's License Law for one of All roofs hall be inspected prior to any roofing material being installed.If a roof is :he following two reasons: installed v ithout first obtaining an inspection,I agree to remove all new materials for 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, 3usiness&Professions Code) Signature)f Applicant: Date: f,as owner of the property,am exclusively contracting with licensed contractors to ;onstmct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER l hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE [haveand will maintain a Certificate of Consent to self-insure for Worker's ompensation,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 t Health&Safety Code,Sections 25505,25533,and 25534. I will maintain [have and will maintain Worker's Compensation Insurance,as provided for by complian:e with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Cc de,Section 25532(a)should I store or handle hazardous material. Addition:lly,should se equipment or devices which emit hazardous air permit is issued. contaminants as d3oned by the Bay Area Air Quality Management District I will [certify that in the performance of the work for which this permit is issued,I shall maintaincompli ce th 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&,fie Co ,Sections 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,I / become enation' provisions subject to the Workers Com isions of the Labor Code,I must O e ol �orized nt: P P c- forthwith comply with such provisions or this permit shall be deemed revoked. Date: 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 the above mentioned property for inspection purposes.(We)agree to save nnify and keep harmless the, ity of Cupertino against liabilities,judgments, Lender's Address sits,and expenses which m acc a against said City in consequence of the granting of this ermit.Ad 'iona y,the applicant understands and will comply ARCHITECT'S DECLARATION with all n -point s 1 ons per the Cupertino Municipal Code,Section 9.18. I V 1 understz nd my plans shall be used as public records. Signature 1 Date d -�'J Licensed Professional J CITY OF CUPERTINO 4 ITEMS OF 30 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 35702039 . 00 DATE ISSUED. . . . . . . : 08/03/2C10 RECEIPT #. . . . . . . . . : BS000011064 REFERENCE ID # . . . : 1008001E SITE ADDRESS . . . . . : 10317 MIRA VISTA RD SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTII�O IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : DAVID CLOUGH ADDRESS . . . . . . . . . . : 10317 MIRA VISTA RD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : RANDO APA HVAC, INC CONTRACTOR . . . . . . . : RANDO, U-IM LIC # 8050 COMPANY . . . . . . . . . . : AAA FURNACE & AIR CONDITIONING ADDRESS . . . . . . . . . . : 1712 STCNE 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 4, 500 . 00 1 .00 0. 00 1. 00 0 . 00 1BPWHEATER PER HEATER 1 . 00 2E . 00 0. 00 25. 00 0 .00 1PPERMITFE FLAT RATE 1. 00 42 .00 0. 00 42 . 00 0 .00 1TRAVDOC FLAT RATE 1. 00 4 . 00 0. 00 42 . 00 0 .00 ------- --- ---------- ---------- ---------- TOTAL PERMIT 11( . 00 0 . 00 110. 00 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- ---- ---------------- CHECK 1, 275 . 00 #36E30 --------------- TOTAL RECEIPT 1, 275 . 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- - ------- ---------------------------- 518 WATER HEATER CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: I DATE: REVIEWED BY: APN: BP#: *VALUATION: 1$4,500 MPETIT TYPE: Plumbing Permit PLAN CHECI{TYPE: Alteration /Addition / Repair PRIMARY t ?t_ APPLICATION 1 RPWH USE: SFD or Duplex �,t ;_ q :fi TYPE: �gW as O0 3 � APPLIANCE/EQUIP TYPE CAPACITY FEE ID QTY BP FEES Water Heater 1BPWHEAT 1 $25 TOTALS: $25.00 Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: 1PPERMIT 7-1 Other Plumb Insp. 0.0 7hrs $42.00 F T71 NOTE. Thesefees are based on the preliminary in ormation available c nd are on! an estimate. Contact the De t or addn'l info. FEE ITEMS (Fee Resolution 09-051 F_ff 7,"1,"09) FEE Q7'Y/FEE MISC ITEMS F-1 PME Plan Check: $0.00 PME Unit Fee: $25.00 PME Permit Fee: $42.00 Work Without Permit? Q Yes No $0.00 Travel Documentation Fee: ITRAVDOC $42.00 ; c, Select an Administrative Item lde Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $110.0or $0.00 TOTAL FEE: $110.00 Revised: 7/27/2010 CITY OF CUPI�RTINO WATER HEATER CUPEkTINO PERMIT APPLICATION FORM APN# - Date: Building Address: Lt ...; I 1 1-V'N ► rc, Owner's Name: L I C u Phone #: 2 '� Contractor: Ati rtet,o N 4'+c h-r},- /=u 1-1v Phone #:4-It - Fax #:tfe?� -- s -7 Cupertino Business License #: Contractor State License #: -7&8-K -7 / Contact• i^ �4, { ; Phone #: qo i Z,, 3 v Fax #: 4!G - % 7 Building Permit Info: Bldg ❑ Elect El� Plumb [ Mech Residential ©- Commercial ❑ Job Description: P 14r e ��>��� ., hz l� �` Strapped ❑ On Platform ❑ Bonded New Location ❑ Replacement []� Valuation (cost of project): U �- G& c) Project Size: Express El.-�andard ❑ Large 1:] 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 M.Indoor Air Quaft and Finishes 1.Use LowlNo-VOC Paint 1 IAQ/Healt i pts y=yes 0 2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Healt i pts y=yes 0 3.Use Low/No VOC Adhesives 3 IAQ/Healt i 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/Healti pts y=yes 0 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Healt-t pts y=yes 0 7.Seal all Exposed Particleboard or MDF 4 IAQ/Healt i. pts y=yes 0 8.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/Healt t 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 1 ! Total Points Available: 1 1401 1301 57 Total Points Project Received: 01 01 0 G:data/procs/greenbuildingguidelnes/remodelers/greenpointsfinal2`Y£D4protected.xls Building Department City Of Cupertino 10300 Torre Avenue Cupertino,CA 95014-3255 91 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: /L �i-1 4'l t�C- �' 0�2 C4 PERMIT# � �_"�. c..�; '; i < OWNER'S NAME: PHONE# 4/�'3 2S 3 GENERAL CONTRACTOR: BUSINESS LICENSE# ADDRESS: I ) ► L �'` r /�� -� CITY/ZIPCODE:-5�*"�' *Our municipal code requires all businesses working in the city ro have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCYIIHAVS) WILL BE E OBTAINED ABCITY OF CUPERTINO UNTIL THE GENERAL CONTRACTOR AND ALL ONTRACTOR3 BUSINESS LICENSE. I am not using any subcontractors: Date Signature Please check applicable subcontractors and complete the fi)llowing information: SUBCONTRACTOR BUSINESS NAN/lE 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 ile `7' Owner/Contr or Signature Date