08070078 CITY OF CUPERTINOr *. tac.»
BUILDING DIVISION PERMIT ,RCONTILAGTQRITFORM.AI'I�IO,,N�,�",
LNG RFSs: PERMIT NO.
BUI
w571 ? 3 LOMITA AVE FELIX MENDELSON 08070078
OWNER'S NAME: - PERMITLSUEDATE
FELIX MENDELSON 21918 LOMITA AVE 07/14/2008
NE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
SOI LICENSED CONTRACTOR'S DECLARATION O O O
m JobDescri tion
1 ion? affirm Ns 1 3 Iisvetl under and
froom meChapter 9(mmmexing p
with Section]000)of Division 3a(the Business and l4ofcuiom Code.and my license is $V(,' UPGRD TO 220 & RE—WIRE
u. in fell form end ettm
j Incense Clw Contractor�Fp Dau ARCHITECTS
L
W7 As Mail
DECLARATION
-U I unalcrsunJ my plans Mall ho used u public records
d
[C H Licensed Profcssionsl
5 OWNER-BUILDER DECLARATION
1 hereby affirm u
that I am exempt from Am ConracYs license Law for IW
00 following reason.(Section 701.5.Business and Professions Care:Any city or county
S
-9
which squirm a permit out cnmhuck Wur,improve,demolish,or mpur any erection
in prior w is issuance.also requires this applicant for such permit to flet a signed sutemcnt
< ubuheislicrosedpursumttotheprovisions ofthe ConwclofslJmnse Law(Chapter 9 Sq.Ft.Floor Area Valuation
9 (cammcncing with Section 700M Of Division 3 or ton Business and Profeusiens Cede)or $6500
the has Is attempt Iherefrgm and the bus for the,alleged exemption.My violation of
S.A.7031.5 by shy applicant for a permit subjects the applicant in a civil penalty of
not more Nan five hundred dolls ISM 35715002 .W Number Occupancy Type
0 I,u owner of the pmpeny,or my employem who wages u tuir sole eompcmdw,
wWdo Newark.and NesWcturtumhMendedwoffm forsale(s .7W.Bu nes
and Professions Code:The Comrxlors Limine Law don not apply an an Owner of Required Inspections
property who builds or i mprows Nunn,aM who does such work lintel f or trough his
own employee,provided Nat such improtemmu art mtrnendW oroRered fm sees If.
however,Ne bending or impmvsment Ia sold within one year of mmpdtion.An Owner-
buil will lour:As bmtlm of paving dust he did rot Wild in improve for pugme of
sb,I
.u owrher of the Property.am exclusively cinaacting w' rend emo scbn d
de:
meet Ne psojeu(Sec.]Oso,Businear otic Rof o )The Dissonances U. .
cans Lawn not eyd as owner of i orlmprowalmoortand. .,.
wWconra for Pro' con tlpurmumt to she Contractors
Lice x
❑1 em under B$PCferfeisreaWn
Owns Dau
'SC D/f�QLA ATION
liewin
I by eRrm M c PeOu aC f d foldwing deco a Ons:
Ihowsd mil maroons. aNOmeofeenscntdself--ivurtfmwortelsComPen-
.I..u Provided for by Sends 3700 of du Labor Code,for Ne performance Of Ne
work for which this Permit is found.
❑1 have and will maimain Worker's Compensation durance,as mgrired by Section
37W of Ne labor Code,for be performance of Ne wink for which this Permit is issued. '
My Workmu Compeua6on Insurantt carrier and Policy number s: .
Carder. Polley No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURA fE
(ThusectmcNuutbecumPlet Ihap, n1sleramehunalretldolluf[100)
m fuss)
I unify Not in a thin permit u bound,I shall not
cmployanYpe ain m ei 'n oN o ortComPensaton
taws of Calif i m /
Applicant
NOTICE TO cni0ca f Etterepfion.you shard
bseo r e sub' ry pro a Of lW labor Code.you much
,JO fonawlthco ply wi suelli is Permit Mall be decreed revoked.
y N CON UCTION LENDING AGENCY
F Ite.by afRrm that is a construction lending agency for to Pedurmanceof
fLi> the wart for which this permit u farcical(sec.Mr?,civ.c.)
<] tendo(,Name
,M,Z Lanalers Andres
U C) I certify that I haw read this application and sou Nu the shove information u
U, contest.I agree N comply wife all city and county onsma ew and sou laws missing d
Wilding construction,and hereby authodm rep utiws of this city d cher upon to
[A shove-mc oven prop"
WIC for imp pis s
I„r gy )a mw.lade P hsrmles to City or Cupertino against
fA liabili' ,Jon s.c a hist prey in any way ensue again hid City
V Z me a gran f th' rrnIL
AP If DS D WILL COMPLY WITH ALL NON-POINT Issued by: Date
S UR E
t �-
Re-roofs
sign orA i •r P�Ar C
DISCI-OSU Da Type of Roof
Will to appliexnt m fuum Wilding cmpmt son or hannlc has fou msurisl
u deOcd by to Cupertino Municipal Code.Chapter 9.13,and Ne Health and Safety
code,sedan 2553x,)+ All roofs shall be inspected prior to any roofing material being installed.
[Dy.
Will hass lions or future Wilding Occupant ore equipment If a roof is installed without first obtainingan inspection,I agree to remove
Pp [ P a it Qu or Mang which pe
Dour«gMua air conuminanN udefined by the Ray Area Air Quality Management all new materials for inspection.
❑Yes A❑NNool
I hays read hesardwsm urjs�S mquimmcmv ruder Chapter 6.95 of to Califor.
niaflcahh safe s 3 533m,12553a.Irndcsundthsifde Wiwi,
dons me w. flys y m3pomiblRty W retry the occupun of the
ne ul m nil ( Tri t arr mar.Cmtre,earOccu army. Signature of Applicant Date
owners anfem a da ret D,te All roof coverings to be Class" "or better
CITY OF CUPERTINO
. 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . . 35715002 . 00
DATE ISSUED. . . . . . . : 07/14/2008
RECEIPT # . . . . . . . . . : BS000005448
REFERENCE ID # . . . : 08070078
SITE ADDRESS . . . . . : 21918 LOMITA AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : FELIX MENDELSON
ADDRESS . . . . . . . . . . : 21918 LOMITA AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : FELIX MENDELSON
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : FELIX MENDELSON
ADDRESS . . . . . . . . . . : 21918 LOMITA AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . . :
•
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 6, 500 . 00 0 . 70 0 . 00 0 . 70 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 82 . 28 0 . 00 82 . 28 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 82 . 28 VISA
--------------
TOTAL RECEIPT 82 .28
•
0e0-7 00-7�
CITY OF CUPERTINO
CIN OF
• CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # ,3G, 7 /6 O oa Date:
Building Address:
Z L .T v� �ceP�Qr1� a 9So(�
Mailing Address (if different from building address):
Owner's Name: Phone#:
`rQ I S 833
Contractor: Phone:
W 1J0-4L_ S Ck I L Fax:
Contractor License#:
Cupertino Business License#:
Contact: Phone:
•
Residential Commercial Fax:
Job Description: S,�0lCE L) 4P&P-W� .T 2Z D }�
r
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ IUIII/V-A ❑ IVIII B, IV-HT, V-B
Valuation: Square Footage:
Project Size: Ex ress Standard ❑ Laze ❑ Major p
Green Building! Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set& the sheet index.
• Points Achieved:
For help, contact Build it Green at www.buBditgreeg.org
Revised � ��
CITY OF CUPERTINO
C ZYOF
CUPERTINO GENERAL BUILDING
PERMIT APPLICATION FORM
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1 BBOILERI For the installation or relocation of ea M
boiler/compressor to &including 3
horsepower, or ea absorption sys to &
incl 100,000 Btu/h 29.3kw)
1 BBOILER2 Installation/relocation of ea M
boiler/compressor over 3 horsepower
to & incl 15 horsepower, or ea
absorption sys over 100,000 Btu/h
1BBOILER3 Installation/relocation of ea M
boiler/compressor over 15 horsepower
to & incl 30 horsepower, or ea
absorption sys over 500,000 Btu/h to
&incl 1,000,000 Btu/h
1BBOILER4 • Installation/relocation of ea M •
boiler/compressor over 30 hosepower
to & incl 50 horsepower, or for ea
absorption sys over 1,000,000 Btu/h to
& incl 1,750,000 Btu/h
1 BBOILER5 Installation/relocation of ea boiler or M
refrigeration compressor over 50
horsepower, or ea absorption sys over
1,750,000 Btu/h
1BAPPLOTH For ea appliance or piece of equip M
regulated by this Code but not classed
in other appliance categories, or for
which no other fee is listed in this
code.
lELECINSP Other Electrical Inspections (per hour) E
1MECHINSP Other Mechanical Inspections (per M
hour)
1PLMBINSP Other Plumbing& Gas Inspections P
(per hour) •
1MEETINGIHR Application Meeting B
CITY OF CUPERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPERTINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
ACOUSTICAL
REVIEW
IACOUSFDW SFDWL/Duplex New B
IACOUSRESAD SFDWI/Duplex-Addition/Alteration B
IACOUSCOM Multi-Family/Commercial B
CHIMNEY'S
]CHIMNEY Chimney B
1CHIMNEYR Chimney Repair B
FENCES
1FENCE>6FT Non-masonry, over 6 ft in height B
1 FENCEMAS>6 Masonry, over 6 ft in height B
FIREPLACES
1FIREPLMAS Fireplace Masonry B
1FIREPLFAB Fireplace Pre-Fabricated/Metal B
1FLAGPOL>20 Flag pole (over 20 ft in height) B
IMODUSTRU Modular Structures B
FOUNDATIONS
IFOUNDREP Foundation Repair B
1 PILECAST Pile Foundation Cast in place concrete B
1 PILEDRIV Pile Foundation Driven(steel,pre- B
stressed concrete
3 of 5
alF
CITY OF CUPERTINO
GENERAL BUILDING APPLICATION
CUPERTINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
IGENCOM
RETAINING
WALL(CONCRETE
OR MASONR
1RETSTN Standard (up to 50 ft) B
1RETSP310 Special Design, 3-10' high (up to 50 `) B
1RETSP10 Special Design, over 10' high(up to B
50'
1RETCRB< Gravity/Crib Wall, 0-10'high(up to B
50 ft
1RETCRB> Gravity/Crib Wall over 10' high (up to B
50 ft
SHED-(EACH) Shed Over 120 sq ft B •
SIDING
1 SIDEST/BK Siding, Stone & Brick Veneer B
interior/exterior)
1 SIDEOTHER Siding all other B
SKYLIGHTS
1 SKYL<10 SF Skylight less than 10 sf B
1 SKYL>10SF Skylight greater than 10 sf or B
structural
ISTAIRS Stairs-first flight/ea addt'l B
STORAGE RACKS
1 SRACKS<=8 Storage Racks 0-8' high (up to 100 sf) B
1 SRACKS>8 Storage Racks over 8' high (up to 100 B
st)
E_ _
4of5
CITY OF CUPERTINO
c'TM°r GENERAL BUILDING APPLICATION
CUPEQ INO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
ISTUCOAP Stucco Applications (up to 400 sf B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door ea 8 windows
1WINMEWSTR New Window-structural shear B
wall/masonry includes plan ck fee
r IEPERMITFEE Electrical Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
IPPERMITFEE Plumbing Permit Fee P
1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1 PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-stand alone
i1BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
1TRAVDOC Travel &Documentation B
1BUSLIC Business License B
5 of 5
Green Building Plan Check
Index of Green Building Points/Categories
• .A. Category Example of an Index or Table of Green Plan Sheet or Page Points
Building Points Categories that must be
shown and referenced on the Project
Plans See below
B. Site 9. Install H.E. Irrigation, (details/spec)' L-1 2 points
11. Permeable Paving, Note L-1 2 points
C. Foundation 1. Use 15 % Flyash Concrete, (note) S-1 5 points
D. Structural 3. Uses Wood I-Joist, (See Spec.) S-2 2 points
5. Use Truss with heels, (detail) S-2 2 points
6. B. OSB Sheathing, detail S-2 2 Points
E. Ext. Finish 1. Composite Decking, (Note/Spec.) A-3 2 points
4. B. Fiber Cement Siding, (Note/Spec. A-4 2 points
F. Plumbing 1. Insulate all H.W. pipes, (Note/Spec.) P-1 2 points
5. Tankless W.H., (Note/Spec.) A-2 2 points
11. A 2500 Gal. Tank, (Note/Spec L-1 10 points
G. Electrical 4. E. Ceiling Fans, (Note/Spec.) A-3 4 points
H. Appliances 1. Energy Star Dishwasher, (Note/Spec.) A-3 1 point
3. Energy Star Refrigerator, (Note/Spec. A-3 1 oint
P. Other 1. List Green Features on Plans A-1 1 point
TOTAL POINTS1 40 points.
•
I
Plan Review Process Work Book Page-12-Revised 3/25/08
Green Points Rating System for Remodeling Projects
Due to the diversity of remodeling project types,assigning a'total points'value to a project to be considered environmentally friendly is
not feasible.However,25 measures have been highlighted to signify that every effort should be made to incorporate them into your •
projects. These items have been chosen based upon their impact on the environment and the health of the home in coordination with
ease of implementation and relative low cost. These measures can be used as a starting point for'greening'your project.
AL Site INPUT Resources Energy IAD/Health
1.Recycle Job Site Construction 8 Demolition Waste
65%=1 point,,75%= 2 points;-BO%=4 points up to 4 Resource pts 0
2.Salvage Reusable Building Materials, 4 Resource pts y=yes 0
3.Remodel for Mixed Use,Adaptive Reuse,and
Historic Preservation 4 Resource pts y=yes 0
4.Protect Native Soil 2 Resource pts y--yes 0
5.Minimize Disruption of Existing Plants 6 Trees 1 Resource pt Y--yes 0
6.Implement Construction Site Stormwater Practices 2 Resource pts y--yes 0
7.Protect Water Quality with Landscape Design 2 Resource pts y=yes 0
B.Design Resource-Efficient Landscapes and Gardens 4 Resource pts Y_—Yes 0
9.Reuse MatehalslUse Recycled Content Materials
for Landscape Areas 2 Resource pts y--yes 0
10.Install High-Efficiency Irrigation Systems 2 Resource pts y--yes 0
11.Provide for On-Site Water Catchment/Retention 2 Resource pts y--yes 0
1 1 1
B.Foundation
1.Incorporate Recycled Flyash in Concrete
25%Recycled Flyash=2 points;Add 1 point for every 10% •
increase of flyash,up to 5 points up to 5 Resource pts 0
2.Use Recycled Content Aggregate 2 Resource pts y=yes 0
3.Insulate Foundation/Slab before backfill 3 Energy pts y=yes 0
1 1 1
C.Structural Frame
1.Substitute Solid Sawn Lumber with Engineered L"umber 3 Resource pts y=yes 0
2.Use FSC Certified Wood for framing
(For every 10%of FSC lumber used=2 points,up to 10) up to to Resource pts. 0
3.Use Wood IJoists for Floors and Ceilings 2 Resource pts y=yes 0
4.Use Web Floor Trusses 2 Resource pts y--yes 0
5.Design Energy Heels on Trusses 6'or more 2 Energy pts y--yes 0
6.Use Finger-Jointed Studs for Vertical Applications 2 Resource pts y--yes 0
7.Use Engineered Studs for Vertical Applications 2 Resource pts y=yes 0
B.Use Recycled Content Steel Studs for Interior Framing 2 Resource pts y=yes 0
9.Use Structural Insulated Panels(SIPS)
a.Floors 3 Energy pts y=yes 0
b.Wall 3 Energy pts yryes 0
C.Roof 3 Energy pts y=yes 0
10.Apply Advanced Framing Techniques 4 Resource pts y=yes 0
11.Use Reclaimed Lumber for Non Structural Applications 3 Resource pts y--yes 0
12.Use OSB
a.Subfloors 1 Resource pt y--yes 0 •
b.Sheathing 1 Resource pt y--yes 0
1 1
• I.windows INPUT Resources Energy [ACIIHealth
1.Install Energy-Efficient Windows
• a.Double-Paned 1 Energy pt yeses LO b.Low-Emissivity(Low-E) . 2 Energy pts y=yesc.Low.Conductivity Frames 2 Energy pts Y=Yes2.Install Low Heat Transmission Glazing 1 Energy pt y=Yes
1 1 1
J.Heating Ventilation and Air Conditioning
1.Use Dud Mastic on All Duct Joints 2 Energy pts Y=Yes 0
2.Install Ductwork within Conditioned Space 3 Energy pts Y=Yes 0
3.Vent Range Hood to the Outside i IAQ/Health pt y--yes p
4.Clean all Duds Before Occupancy 2 IAQ/Health pts ycyes 0
5.Install Solar Attic Fan 2 Energy pts y--yes 0
6.Install Attic Ventilation Systems 1 Energy pt Y=Yes 0
7,Install Whole House Fan 4 Energy pts Y=Yes p
B.Install Sealed Combustion Units
a.Furnaces 31AQ/Health pts yryes 0
b.Water Heaters 3 IAO/Health pts y--yes 0
9.Replace Wall-Mounted Electric and Gas Heaters with
Through-the-Wall Heat Pumps 3 Energy pts Y--yes 0
10.Install 13 SEER/11 EER or higher AC with a TXV 3 Energy pts y--yes 0
11.Install AC with Non-HCFC Refrigerants 2 Resource pts y=yes 0
12.Install 90%Annual Fuel Utilization Efficiency(AFUE)Furnace 2 Energy pts Y=Yes 0
13.Retrofit Wood Burning Fireplaces
• a.Install EPA certified wood stoves/Inserts 1 IAQ/Health pt y=yes 0
b. Install/Replace Dampers 1 Energy pt y--yes 0
c.Install Airtight Doors 1 Energy pt Y--yes p
14.Install Zoned,Hydropic Radiant Heating 3 Energy pts Y=Yes p
15.Install High Efficiency Filter 41AQ/Health pts y--yesp
16.Install Heat Recovery Ventilation Unit(HRV) 5[AO/Health pts y--yes 0
17.Install Separate Garage Exhaust Fan 31AQ/Health pts yr--- as 0
1 1 1
K Renewable Energy and Roofing
1.Pre-Plumb for Solar Water Heating 4 Energy pts Y=Yes 0
2.Install Solar Water Heating System 10 Energy pts Y=Yes 0
3.Pre-Wire for Future Photovoltaic(PV)Installation 4 Energy pts Y=Yes 0
4.Install Photovoltaic(PV)System
(1.2 kw=6 points,2.4 kw=12 points,3.6 kw=18 points) Up to 18 Energy pts p
6.Select Safe and Durable Roofing Materials 1 Resource pt Y=yes 0
7.Install Radiant Banner 3 Energy pts y--yes p
1 1 1
L.Natural Heating and Cooling
1.Incorporate Passive Solar Heating 5 Energy pts Y=Yes p
2.Install Overhangs of Awnings over South Facing Windows 3 Energy pts y--yes p
3.Plant Deciduous Trees on the West and South Sides 3 Energy pts y=yes p
• 1 1 1
I
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform:
A. All the work authorized by this permit
B. ✓ A portion of the work
C. _ None of the work
If B or C is checked,co m Tete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. All of the work
B. 7A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
• 3. I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
performed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (reve s e).
Property Owner's Signature: Date: /
Job Address: ?4:i4 9' (T:A= 14T_ Permit#
I.
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
• Department.
Us
City of Cupertino Building Departmento
CITY OF 10300 Torre Avenue
C U P E IST I N O Phone: (408)777-3228
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of .
the property improvements specified.
For your protection you should be aware that as owner-builder you are the responsible party of record
on such a permit. Building permits are not required to be signed by property owners unless they are
personally performing their own work. If your work is being performed by someone other than yourself, you
may protect yourself from possible liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a
business license from the city or county. They are also required by law to put their license number on all
permits for which they apply.
If you plan to do your own work,with the exception of various trades that you plan to subcontract,you
should be aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family, and the work
(including materials and other costs) is$200 or more for the entire project,and such persons are not licensed as
contractors or subcontractors, then you may be an employer.
If you are an employer,you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding,federal social
security taxes,workers' compensation insurance, disability insurance costs, and unemployment compensation •
contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are
especially serious with respect to workers' compensation insurance.
For more specific information about your obligations under federal law,contact the Internal Revenue
Service (and, if you wish, the U.S. Small Business Administration). For more specific information about your
obligations under state law,contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are allowed to
perform their work personally or through their own employees,without a licensed contractor or
subcontractor, only under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder
building permit, erroneously implying that the property owner is providing his or her own labor and material
personally. Building permits are not required to be signed by property owners unless they are performing
their own work personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License
Board in your communityor at 1020 N Street,Sacramento,California 95814.
Please complete and return the enclosed owner-builder verification form so that we can confirm that
you are aware of these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
Building Department, •
City of Cupertino
Printed on Recycled Paper
fc-1 Community Development
10300 Torre Avenue
�a ' ./' Cupertino CA 95014
"R�, .
Telephone(408) 777-3228
CITY Of Fax(408)777-3333
*UPEf�TINO
Building Department
JOB ADDRESS: PERMIT #
2 Lq 1 19 Lol-t OPO?00'7 (P-
OWNER'S NAME: _L) H6 l t-<4 Z PHONE # -g
GENERAL CONTRACTOR _ FAX #
I
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followinginformation:
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 Rock
T'
0Y
z actor Signature Da are