13090020 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10546 MERRIMAN RD CONTRACTOR:PAYLESS WATER PERMIT NO:13090020
HEATERS
OWNER'S NAME: CLAYBORN CHARLES M AND MICHELS 24895 AVENUE ROCKEFELLER DATE ISSUED:09/05/2013
OWNER'S PHONE: 4082528723 VALENCIA,CA 91355 PHONE NO:(661)775-2944
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL
6
License Class 3(.P Lic.#I 8 31D 94(D REMOVE&REPLACE(E)50 GAL WATER HEATER,SAME
SS LOCATION
Contractor Date
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:
to\� 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:$1700
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:34216114.00 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 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 DAYS FROM -Ef1 INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Date:
granting of this permit. Additionally,the applicant understands and will comply
with allnon-p int source regulations per the Cupertino Municipal Code,Section
9.18.
n-�-13 RE-ROOFS:
Signatu Date 6 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. I 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(x)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,Sectio�25505,25534.Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorizd 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 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 Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
GENERAL PLICATION
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CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10546 MERRIMAN RD DATE: 09/05/2013 REVIEWED BY: MELISSA
APN: 34216114 BP#: `VALUATION: 1$1,700
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION PRWHEATR
USE: p PERMIT TYPE:
WORK REMOVE& REPLACE E 50 GAL WATER HEATER SAME LOCATION
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Heater 1PRWHEATR 1 # $28
TOTALS: $28.00
.kkc:h. Plan Check Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check
Mech.1"ennia Fee: Plumb.Permit Fee: 1PPERMIT Elec.. Permittee:
Other,9ech.Insp. F-1 I Other Plumb Insp. 0.0 hrs $47.00 (Other Elec.Insp. Lj
r fech.Insp.Fee: PIUF17b. hap.Fee: I-:lce.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). These fees are based on the prefindna information available and are only an estimate. Contact the Dept for addn'l info,
FEE ITEMS (Fee Resolution 11-053 E . 7t 711112) FEE QTY/FEE MISC ITEMS
Plan Cheek Fee:
Suppl. PC'Fee:
PME Plan Check: $0.00
Perinit.Fee:
sup,ol. Insp Fee
PME Unit Fee: $28.00
PME Permit Fee: -F-F $47.00
(.onsfruction Tax:
Administrative Fee: IADMIN $44.00
Work Without Permit? ®Yes (j) No $0.00
Advanced Planning Fees:
Travel Documentation Fee: 1TRAVDOC $47.00
Strong Motion Fee: 1BSEISMZCR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
}.r l _
JIM $167.501 $167.50
Revised: 07/01/2013
Prescriptive Certificate of Com Bance:Residential WAITER HEATER CF-IR-ALT-Water Heater
Dat : Enforcement Agency: Climate Zone#�#of Stories� Permit#
3 12
Site Address:
10,!��(P
Building T e M Single Family a Multi Famil
NOTE: This form is not to be used or New -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
corn onent packages in all climate zones.
Water Heater T7pe/ Distribution Type Number Tank Energy Factor External
Fuel Type (Standard, in System Capacity or Tank
Recirculating)Z (gal) Thermal Insulation
Efficiency R-Value3
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 of
§1506.
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.
• 1 certify that the energy features and performance specifications identified on this Certificate of Compliance conform to the
requirements of Title 24,Parts I and 6 of the California Code of Regulations.
Name: Signature:
l'U,CI�I.la-t'' 61.0 0 k S
LL-cArd)o
Company Date:
PO U less Ulr x r . `7
Address: License:.
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City/State/Zip: Phone:
_77> -2q �
For assistance or questions regarding the Energy Standards,contact the Energy Hotline at 1-800-772-3300.
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