13040197 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20206 FOREST AVE CONTRACTOR:MIKE COUNSIL PERMIT NO:13040197
PLUMBING INC
OWNER'S NAME: LEONARDI DIANA M 1915 O'TOOLE WAY DATE ISSUED:04/30/2013
OWNER'S PHONE: 4089266598 SAN JOSE,CA 95131 PHONE NO:(408)2724900
❑ LICENSED CONTRACTORSDECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIALE]
License Class C�3� Lii,..#_�6 r7 (Z b I ? REMOVE AND REPLACE 40 GALLON WATER HEATER
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Contractor (�Q 6f L nSr I �^�w'b;V1-Yate 4
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:$3004
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:31624021.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WIT8 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DA OM LAST CALLED INSP ION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Issued by Date: Y,�b
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source re ul�attiio/ns per the Cupertino Municipal Code,Section
9.18. CiY/'
_3 3 RE-ROOFS:
Signature Date 1 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.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole compensation,
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 HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Secti s 2550%2553 ,and 25534. (�
Section 3700 of the Labor Code,for the performance of the work for which this ��ll� Date: ` �^
Owner or authorized agent:
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 CONSTRUCTION LENDING AGENCY
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 must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the.applicant understands and will comply
with all non-point source regulations per the CupertinoMunicipal Code,Section Licensed Professional
9.18.
Signature Date
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GENERAL PERMIT APPLICATION MEP .-
i:i,::.CPMMUNITY
DEVELOPMENT DEPARTMENT•BUILDING DIVISION, a
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(4.08)777-3228•FAX(408)777-3333•buildingacupertino.org MISC
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CONTACT:NAME PHONE E-MAIL
STREET ADDRESS CTTY,STATE,ZIP FAX
❑OWNER 11 OWNER-BUILDER, ❑OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER .❑ DEVELOPER ❑TENANT
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_ USE'1 of ; SM of DUPLEX ❑ MULTI-FAMILY PROJECT IN WMDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑.YES
BUILDING :❑COMMERCIAL URBAN INTERFACE AREA ❑ NO ROOD ZONE ❑NO EICHLER HOME? ❑NO
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By lm aY lgn a below;:I certify to leach of the following: I am the property owner or authorized agent to act o e operty owner's behalf. I have read this
pp he iri�ormatjon'I have provided is correct. I have read the Description of Work and verify itis acc e. I agree to comply with all applicable local:
ord1 ces and state laws relatinglto ilding co ctio . I authorize representatives of Cupertino to enter the abov/e�-(identified property for inspection purposes.
Signature of Apolican�/Agegt. Date:
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SUPPLEMENTAL INFORMATION REQUIRED
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CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: DATE: 04/30/2013 REVIEWED BY: mendez
APN: BP#: 'VALUATION: 1$3,004
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: PRWHEAT i
WORK remove and replace water heater
SCOPE
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L1ech..Ptan Cherk Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check
vT,,, .Perinit Fee: Plumb.Permit Fee: IPPERMIT Elec.Permit Feu::
LC)ther Afech.Insp. Other Plumb Insp. 0.0 hrs $45.00 Oilier F.lec.Insp.
lh,",A Imp.Fee: Plumb. Insp.Fee: Elec,Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). Theseees are based on the prelimina information available and are only an estimate Contact the Dept-for addn'l info,
FEE ITEMS (Fee Resolution 11-053 E„ff. 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 0 # Plumbing
Suppl.PC Fee: (E) Reg. ® OT 0.0hrs $0.00 $27.00 1PRWHEATR Water Heater
PME Plan Check: $0.00
Permit Fee: $0.00
Supp/.Insp.Feed Reg. Q 0T :p Q hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $45.00
ConsIt-action Tax:
Administrative Fee: IADMIN $42.00
Work Without Permit? 0 Yes (E) No $0.00
Advanced Planning Feer $0.00 Select a Non-Residential 0
Travel Documentation Fee: ITRAVDOC $45.00 Building or Structure
i
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1..00
$160.50
$133.50 $27.00
Revised: 04/29/2013
INSTALLATION CERTIFICATE CF-6R-MECH-01
Domestic Hot Water (Page 1 of 2
Site Address: Enforcement Agency: Permit Number:
20 4 C Fo rets e- LIU Ch
I I
1. WATER HEATING SYSTEMS:
Distribution Rated
CEC Type If #of Input(kW Tank Standby
Heater Certified Mfr Name&Model (Std,Point-of- Recirculation, Identical or Volume Efficiency Loss
Type Number Use etc) Control Type Systems Btu/hr)t (gallons) (EF,RE)I (%)1
a- of F w t�2 libNleSk, footle— PJot1t; L1011)t7 LE7q�{�{O�� hone
t1�,44c�6 FR�-3gN
Note]:For small gas storage(rated input less than or equal to 75,000 Btu/hr),electric resistance and heat pump water heaters,list
Energy Factor(EF).For large gas storage water heaters(rated input of greater than 75,000 Btulhr),list Recovery Efficiency(RE),
Thermal Efficiency,Standby Loss and Rated Input. For instantaneous gas water heaters,list the Thermal Efficiency and Rated Input.
2. Mandatory Measures
TO COMPLY-ALL BOXES MUST BE CHECKED
❑ §110-§113:Water heaters,showerhead and faucets are certified by the California Energy Commission.
§1500):Water System Pipe and Tank Insulation.And Cooling Line Insulation
1. Storage tank insulation
❑ A.Storage gas water heaters rated with an Energy Factor no greater than the federal minimal standard are
externally wrapped with insulation having an installed thermal resistance of R-12 or greater;and
❑ B.Unfired storage tanks or other indirect hot water tanks have R-12 external insulation or R-16 internal
insulation where the internal insulation R-value is indicated on the exterior of the tank.
2. Water piping and cooling system line insulation thickness and conductivity
❑ First 5 feet of hot and cold water,pipes closest to water heater tank,non-recirculating systems,and entire
length of recirculating sections of hot water pipes are insulated per Standards Table 150-B;and
❑ Pipe insulation for steam hydropic heating systems or hot water systems>15 psi,meets the requirements of
Standards Table 123-A.
❑ Insulation is protected from damage,including that due to sunlight,moisture,equipment maintenance,and
wind.
❑ §151(fl8D:If indicated on the CF-1R,all hot water piping that runs from the hot water source to the kitchen fixtures is
insulated per Standards Table 150-B.
2008 Residential Compliance Forms August 2009
INSTALLATION CERTIFICATE CF-6R-MECH-01
Domestic<'Ilot Water
Site Addressi Enforcement Agency: Permit Number:
202
3. Central Water Heating in Buildings with Multiple Dwelling Units(required for prescriptive)
TO COMPLY-ALL BOXES MUST BE CHECKED
❑, All hot water piping in main circulating loop is insulated to requirements of§1500)
❑ Central hot water systems serving six or fewer dwelling units which have(1)less than 25' of distribution piping
outdoors;(2)zero distribution piping underground;(3)no recirculation pump;and(4)insulation on distribution
piping that meets the requirements of Section 1500)
❑ Central hot water systems serving more than 6 dwelling units-presence of either a time control or a
time/temperature control
DECLARATION STATEMENT
• I certify under penalty of perjury,under the laws of the State of California,the information provided on this form is true and correct.
• I am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction,or an authorized
representative of the person responsible for construction(responsible person).
• I certify that the installed features,.materials,components,or manufactured devices identified on this certificate(the installation)
conforms to all applicable codes and regulations,and the installation is consistent with the plans,and specifications approved by the
enforcement agency.
• I reviewed a copy of the Certificate of Compliance(CF-1R)form approved by the enforcement agency that identifies the specific
requirements for the installation. I certify that the requirements detailed on the C174R that apply to the installation have been met.
• I will ensure that a completed,signed copy of this Installation Certificateshall be posted,or made available with the building
permit(s)issued for the building,and made available to the enforcement agency for all applicable inspections. I understand
that a sigged,copy of this Installation.Certificate`is required to.be included with the documentation the builder provides to
the building owner at occupancy.
CompanName: (Installing Subcontractor or General Contractor or Builder/Owner)
t�'l l��- Co�,ns i I P l ctirn b n
Re risible Person's N e:' Resp Bible Perspn's Si ature:
I QU t'r ,(
CSLB License: Date Signed Posi�pn'With Company(Title
2
6r7 6 f Lh t[-3o- 13 }'l��w+4�� 6c v►ic;a
2008 Residential Compliance Forms August 2009