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13050066 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22866 POPLAR OROVE SQ CONTRACTOR:PAYLESS WATER PERMIT NO:13050066 HEATERS OWNER'S NAME: JOSHI SAMEER AND KAVITA SAMEER 24895 AVENUE ROCKEFELLER DATE ISSUED:05/08/2013 OWNER'S PHONE: 4084808923 VALENCIA,CA 91355 PHONE NO:(661)775-2944 I�1 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL LJ COMMERCIAL License Class 011,3A b Lic.# . REPLACE(E)WATER HEATER,SAME LOCATION Contractor � V1G SS OIAP_( A%ai 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:$1500 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:34233019.00 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 WITHIN 180 DAYS T 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 DAY LLED INSPECT N. 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 s with all non- ointsource regulations per the Cupertino Municipal Code,Section 9.18. J RE-ROOFS: Signature Date 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 I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: 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 offered for sale(Sec.7044, Business&Professions Code) 1,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 37.00 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,Sections 25505, 553 and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: 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 CONSTRUCTION LENDING AGENCY 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 tW 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 Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date W� GENERAL PEIWIT APPLICATION � M E P CO1NII.WNITY DEVEZOPMEN I DEPARTMENT•BUILDING DMSION / 1 C3 oo TORN AVENUE-GUPERTINO,CA 95014-3255 Oi4 (408)777=32'2$-FAX(408)777-333-btuldmCftuperim-c � misc CUPERTINO C]ME'�CAL Q��jC`AT QBISCU ANEDUS Pxi}tgTADDRESS a a ICx� fou- sQcxaf AM# 3 q Z 3 3 012 OWNERNAMH PY 4 ear �osG� c P �f80-S g Z MAa. NAME la g car, Cmfrlkc-NAME room SMAM STREErADDRM LTIY,STATf,zap FAX 0 owt4m ❑awmx-armnm II awmm.&c m camiAcm ❑cmn7AcTmAc;mr 0 Am=Em 0 a*maam D Dria=m 13 T aE&w CONIItACSO$NAME `P1aS Wad ( ( T"�'" DDo�-t T (s3�D aysrx CObtPANYNAME BMAII FAX S �. �fle1CCS off & Gits� TI35s 77S-L?Y z a.uc# COMPANY NAME E-MAIL FAX SIREST ADDRESS PSOm USE cwtnumr7C 13 MOL2I*ANUX P EwwH-w- w I1 Yr3 PR T3 7 13 1'LS N-Im-M " El ya BuRn a EIC018AEUMALI�ANHir�FACEABEA Q leo FLOOD mm ❑m cm ol TMAL VALUATION: L s D D v o B7rmYsigut=bdow,lcmtifytoamhaftioc TmathegtoQatyowueror acc appEcaaaaadrhoia£o�sdmIbmvepmvidedisc==:L,Ihmaradthenesrap" ofw0m-sem,iiA a fwitha1F gii�lelast Sigaatc=OfAppficaatlAgeat� AL INFORMATION REQUIRED omcp-USE ONLY ti Q U � 0 SFAi'FDA&D _ U c ❑ LARGE I� Q MAKM -A&Pbfiscff Z011-doc revised 0621/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 22866 POPLAR GROVE SQ DATE: 05/08/2013 REVIEWED BY: MELISSA APN: 342 33 019 BP#: WALUATION: 1$1,500 %PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Du lex PENTAMATION PRWHEATR USE: p PERMIT TYPE: WORK REPLACE E WATER HEATER SAME LOCATION SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Water Heater 1PRWHEATR 1 # $27 TOTALS: �T $27.00Jill _ ,u �. IV VP - ,vtech. Plan Check Plumb.Plan Check 0.0 hrs $0.00 F.lec.Plan(,heck ;llizch. PeriiiitFee: Plumb.Permit Fee: 1PPERMIT Elec. Permit Fee: FViec Jlkx-h.Insp. Other Plumb Insp. 0.0 hrs $45.00Oilier Elec.Insp. .Insp.Fcce: Plumb.hisp.Tec• Elec.Insp,Fee: NOTE:This estimate does not include fees due to other Departments(ie.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc . These fees are based on the prelimina information available and are only an estimate. Contact the Dept-for addn'1 info. FEE ITEMS (Fee Resolution 11-053 E . 7ff 11/12) FEE QTY/FEE MISC ITEMS Plan Check h'ee: Supp 1. PC Fee> PME Plan Check: $0.00 Pert"nit d'ee: Suppl. Insp I ee PME Unit Fee: $27.00 PME Permit Fee: $45.00 (Ams1ruction Tax: Administrative Fee: 1ADMIN $42.00 Work Without Permit? 0 Yes (E) No $0.00 Advanced Planning Iyees: Travel Documentation Fee: ITRAVDOC $45.00 i Strong;Motion Fee: IBSEISMICR $0.50 Select an Administrative Item 131da Stds Commission Fee: IBCBSC $1.00 MY Ws, p $00.50 .00w 'g $160.50 �x_S_a: - Revised: 04/29/2013 Prescriptive Certificate of Compliance:Residential WATER HEATER CF-IR-ALT-Water Heater Date6-'g'1-'5 12: Enforcement Agency: Climate Zone# #of Stories Permit# Site Address: 9aPop lad L)Li-e— 50LLOL Building Type t Single Family o Multi Family NOTE: This form is not to be used or Newly-Constructed Buildings or Additions WATER HEATING List water heaters and boilers for both domestic hot water(DHW) heaters and hydronic space heating. Individual dwelling DHW heaters must be gas or propane fired, and may not exceed 50 gallons. Hot water pipe insulation from the DHW heater to the kitchen(s) and on all underground hot water pipes is required in all component packages in all climate zones. Water Heater Type/ Distribution Type Number Tank Energy Factor External Fuel Type` (Standard, in System Capacity or Tank Recirculating)2 (gal) Thermal Insulation Efficiency R-Value3 aV 6 S-!a-o 6L6 0 I W D a 1. Indicate type(Storage Gas, Heat Pump, Instantaneous, etc) 2. Recirculating systems serving multiple dwelling units shall meet the recirculation requirements of §150(n)_ The Prescriptive requirements do not allow installation of a recirculating water heating system for single dwelling units. 3. The external water heating tanks and pipes shall be insulated to meet the requirements o 150 ' . Declaration Statement • I certify under penalty of perjury,under the laws of the State of California,the information provided on this form is accurate and complete. ® I certify that the energy features and performance specifications identified on this Certificate of Compliance conform to the requirements of Title 24,Parts 1 and 6 of the California Code of Regulations. Name: ? Signature: [U Ck-t,1 z-e, A� Company: Date: Pau [ass 0-4L r Nuc rs 6--g-/S Address: License: p q81 S /AU2tnu e— �C. PL-JLe r City/State/?ip: Phone: e-6, Russ (ki 77-`>- -2R� For assistance or questions regarding the Energy Standards, contact the Energy Hotline at 1-800-772-3300. CF-iR-ALT;5/17/10 Page 1 of 1