08080049 (2) CITY OF CUPERTINO
BUILDING OWSION PERMIT CU1�i=T12e .C:' QRI1�T 'f1ItMA'. IQ "- `
BUILOINGADDRESS: PERMIT NO. '
866 SEPTEMBER DR ARMSTRONG INSTALLATION 08080049
OWNER'S NAME: PERMIT ISSUE DATE
CARL,]. ARTHUR AND BARBARA 4575 SAN PABLO AVE 06/06/2008
NE: SANITARY NO, CONTROL NO.
(510) 777-1234
ARCHTfECUENGINEER: BUIWING PERMIT INFO
BLDG EI.ECI' PLUMB MECH
0 0 0 0
Seop LICENSED CONTRACTOR'S DECLARATION 7b Description
C 1 hemby to irm that I am licensed under provisions of Chapter 9(commp
encing
withSec6m7WU)afDiAion3aftheRusin=andProf=iamCnde.arldmylicnscu RE—RF T/O EXT WDSHK RF& INSTL CLSA GAF CMPSHNGL
n in full foredard eBecL
jg? Uccn:; I Ua.M �y 9� &1/2" CDS SHETHNG 24SQ
e Date V T'S DECLARATION
5 ARCHIIE use u
LA TION
S
(understand my piw ehsil he umtl public records
J U
k Licensed Professional
53 OWNER-exempt ROE DECLARATION
I hereby M.Not 11. exempt from Ilse Canuecmh License c Law for the
O O following moss..(Section 7031.5,Business and improve,
derans Calc:Any city at county
$ which mqulma•permit re c taus th 1.alter,improve,demolish,fi opsin any uroctum
_iry^ priormits issuance.
ensedpn..,to me,the applicant for such Cambiumi'Oiemum file a Law(chapter
FF G
that he is licensed pursuant to the provisions of the Conu.cmr's License law(Chaptm9 Sq.Ft.FIOOC Area Valuation
Y� (commencing with Section 7")of Division 3 of me,Busincomd Profession Code)or $24000
Q 9 Net he is exempt therefrom and Ble basis for the alleged eaempdon.Any vlohtion of
Section 7031.5 by any applicant for a peonit subjects the applicant to a civil penalty of .• Number Occupancy oat mora man five handmd dollars($5am. . 3 6 214 016 . Type
❑I.u owner of the property.or my employ=with wages as their sok campe=tion,
will do the work,and me aVun?ure is Out Intended or aircraft for ale(Sec.7044,Business
and Professions Code:The Coruscate,License Law d=rot apply in an ower of Required Inspections
property who buiIda or improv thereon.and who does such work himself ter through his
awn employ=.provided that such improvements K not intended araBared for sale.IL
however,the building or imp mvemanI is mid within arc year of completion,he owner.
Wilde'
will have the burden of proving IMI he did ml bouts ter improve for purpose of
sale.).
❑1,u Owner of the property am exclusively conuacting with licensed conuamom in
contract me project(Sec 7014.Business and Normal Code:)The Conamcme3 LI- '
cense Law does not apply in an owner of property who builds or haprov Neaman,ad,
who contracts;for such projects with a eonuactar(s)Rammed praam to the Commutes
Licetue law.
❑Iameaemplundo See ,Bk PCfarthumuon
Owmr Dan
WORKER'S COMPENSATION DECLARATION
40 I hereby affirm under penalty of perjury,am of the following detentions:
I ham and will maintain a Canifiate of Con,enuo self-Wum for Workeb Compen-
Mian,as provided far by Section 3700 of the Labor Code,for the performance of me
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,u requited by Section
3700.f the labor Cod,for me perfarmunce of me.,it forwhich this Fund,is Issued.
My Wmr a rar.2 mRvml.ca artier and Polley
Carrier. P f== Polley
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crisis suctionneed na t be cam plead if the permit is far me hmdrN dollars($100)
or leen)
I unify,that in to performance of Ile wort for which this parol,Is issued,I shall not
employ arty person In my mmnfr an as in became subject of me Waf off eompensaBm
Law of California.Dam
Applicant .
NOTICE TO APPLICANT.IL after making this Ceaficate of Exemption,you should
become subject to the Workers Compensation provision,of We Lahnr Cade,you am,
.,z forthwith comply with such provisions or this permit shall be tleemed revoked.
,zw y CONSTRUCTION LENDING AGENCY
FI 1 hereby.1filarn Nat mart is a consuuctinn leading agency far me rmf rmance of
f1i .moi the work fur which this permit is issued(See.3097,Civ.C.)
W Q Lenders Name ,
M z Lenders Address
U O I certify that 1 have mad this application and state that me above information is
U,:'" Correct.I agree to comply with all city and County callowness and sate law,relating in -
p building construction,and hereby mNorim representatives of this city m enter upon the
W glome-mentiomd properly for inspection purposes.
Or (We)agree to save,indemnify,and keep harmlesa the City of Cupertino against
rn liabilitia,judgmonts,com,and expenses which may N any my acetm against aid City
U"� A APPLICANT
afthegnntingar thispetmll, (/
Z APPLICANT UNDERSTANDS ANO WIL C MPLY WITH ALL NON- ISSUed by: Date d"
BO REpALy13O
i.1A.G1!/ NS. � X4 Re-roofs %
SliIislioure of ApplicmUConuaclor Y Date
HAZARDOUS M&SRIALS DISCLOSURE Type of Roof
Will me applicant or future building cccupantaom or handle hmardam material
as defined by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
Cod,Section 14N.25532(e)?
❑Ya All roofs shall be inspected prior to any roofing material being installed.
Will me applicant or future building occupant uac equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hoyardow air contaminants as defined by 0te Bay Area Air Quality Management all new materials for inspection.
Diatom?
❑Ya `��]vNo
I hrvc oal me hmsrdms Materials requirements under Chapter 6.95 of the Califor- 3
mallalm&Safety Cak.S.c.255M.Z533mdM534.1.Wtamditilmebuildi.g
d=not a fly a a unml.arm it u my ponsthilily m notify tho occupant of the ,,
nqulmm w nslbemetpriar 'rsa r,Ccrtifc.m.foccarawy�. )� Signature of Applicant Date
ower or au*otwad agger i Dam- All roof coverings to be Class R' or better
CITY OF CUPERTINO
• 2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36214016 . 00
DATE ISSUED. . . . . . . : 08/06/2008
RECEIPT #. . . . . . . . . : BS000005710
REFERENCE ID # . . . : 08080049 -
SITE ADDRESS . . . . . : 866 SEPTEMBER DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CARLI ARTHUR AND BARBARA
ADDRESS . . . . . . . . . . : 866 SEPTEMBER DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4127
RECEIVED FROM . . . . : ARMSTRONG INSTALLAT
CONTRACTOR . . . . . . . : MITCH FINE LIC # 22581
COMPANY . . . . . . . . . . : ARMSTRONG INSTALLATION
ADDRESS . . . . . . . . . . : 4575 SAN PABLO AVE
CITY/STATE/ZIP . . . : EMERYVILLE, CA 94608
TELEPHONE . . . . . . . . : (510) 777-1234
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- - --- ------ ---- ----------
IBSEISMICR VALUATION 24, 000 . 00 2 .40 0 . 00 2 .40 0 . 00
1REROOFRES SQ FEET 24 . 00 312 . 00 0 . 00 312 . 00 0 . 00
---------- -------- ---
TOTAL PERMIT 314 .40 0 . 00 314 . 40 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
------ --------------- ------------
CHECK 314. 40 #1154
---------------
TOTAL RECEIPT 314 . 40
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
- ---------------------------- ------ ------------------
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
•
og>
CITY OF CUPERTINO
REROOF
OuPER INO PERMIT APPLICATION
APN # oZ cD • C) U Date: 6 ��
Building Address:.i 6 /
b
Owner's.Name: Phone #:
Contractor: 1 Phone #: ,�7
F Fax #:
Cupertino Business Wense #: Contractor License #:
I Zq.5,Z 9
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
o Asphalt Shingles a Asphalt Shingles
;%, Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other (Specify) ❑ Other (Specify)
Number of existing coverings ❑ Provide I.C.B.O. Report #
❑ To be Removed ❑ Provide Mfgr. Installation Specs.
Job Description: U T Q j;r �d,,J
v111�j S C rb (�h�' S
�I �
ciess.A G�� evwp sl�; lt y c�X sIe&,I� ���,��
Residential, Commercial
Green Building: Please complete relevant portion of the Confirmed with Planning Dept. if
Green Building Checklist & attach it to the application or if there are any restrictions: ❑
applicable, include in plan set & the sheet index.
Valuation:
Jv
•I Have Read, Unders nd and Will Com y w'th Cupertino's Tear-Off Policy:
Signature
Revised 6/16/08
CITY OF CUPERTINO
REROOF
CUPE(�TINO FEE SCHEDULE
Number of Fee ID Fee Description Fee Permit Type
Squares Group
1REROOFCOM Re-roof Commercial B 1COMMLROOF
1BSEISMIC0 Seismic Commercial B
2 1RER00FRES Re-roof Residential BISFDWLROOF
/ 1BSEISMICRE Seismic Residential B
1REROOFMRES Re-roof Multi-Family B 1MFDWLROOF
1BSEISMICRE Seismic Residential B
1BUSLIC Business License B
Revised 6/16/08
Community Development Department
Building Division
City of Cupertino
• 10300 Torre Avenue
Telephone: (408)777-3228
Fax: (408)777-3333
Building Department
Subject: Re-roofing policy for the City of Cupertino
1. Prior to permit issuance,you must agree to comply with 2007 IBC Standards
and manufacturers specifications on re-roofing.All roofs are Class "A"per Cupertino
municipal code 16.04.080.
2. New roof coverings shall not be applied without first obtaining all inspection
and written approval from the building inspector. A final inspection and
approval shall be obtained from the building inspector when the re-roofing
is completed.
3. All roofs shall be inspected prior to any roofing installation.
4. To receive a final sign off from the City, the following steps are
required:
1) Pre-inspection and/or tear off approval.
2) In-progress inspection approval.
3) Final inspection approval.
• a) Spark arrester installation.
5. If plywood is installed, a plywood nail inspection is required.
6. Any roofing which is applied without first obtaining an inspection,
will require the removal of all new material down to the sheathing,
so a proper City inspection can be performed.
7. NOTE: If you call for a plywood nail inspection and the job is not ready,
you will be charged a re-inspection fee of$176.18. The re-inspection fee must
be paid before another inspection can be scheduled
IMPORTANT:
1. Flat roofs must have a minimum of 1/4 "per foot slope and demonstrate
that there is no ponding.
2. An I.C.B.O. report is required to be on the job site at the time on inspection.
I understand and will comply with the above stated policy on re-roofing.
Homeowner's Name: J/4 yr C(nr/h ' y�
Job Site Address: 'Gb SPe&�
Roofing Company Name: A C015 r."ry /
Applicant's Signature: Date:_W'
• Greg Cast eel
Building Official
Revised 07/30/08
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 pont
P. Other 1. List Green Features on Plans A-1 1 point
TOTAL POINTS1 40 points
•
•
Plan Review Process Work Book Page-12-Revised 3/25/08
.i
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.
INPUT ReSDurces Energy IAO/Health
rte
1.Recycle Job Site Construction&Demolition Waste
65%=1 point;75%= 2 points;80%=4 points up to 4 Resource pts D
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&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 —J 4 Resource pts y=yes 0
9.Reuse Matehals/Use 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 pts0
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 Lumber 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 10 Resource pts. 0
3.Use Wood I-Joists 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
8.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 D
b.Wall 3 Energy pts y=yes 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
J �-
12.Use OSB
a.Subfloors i 1 Resource pt y=yes D
• L b.Sheathing _ _ ` 1 Resource pt y=yes 0
1 1 1
r
INPUT Resources. Energy AONenith
xtenor rrma
1.Use Sustainable Decking Materials
a.Recycled content 3 Resource pts y=yes 0 •
b.FSC Certified Wood 3 Resource pts y--yes 0
2.Use Treated Wood That Does Not Contain Chromium/Arsenic 1 IAQ/Health pt y=yes 0
3.Install House Wrap under Siding 1 IAQ/Health pt y=yes 0
4.Use Fiber-Cement Siding Materials 1 Resource pt y=yes 0
1 1 1
E.Plumbing
1.Install Water Heater Jacket 1 Energy pt Y_-Yes 0
2.Insulate Hot and Cold Water Pipes 2 Energy pts y-yes 0
3.Retrofit all Faucets and Showerheada with Flow Reducers
a.Faucets(1 point each,up to 2 points) Up to 2 Resource pts. 0
b.Showerheads(1 point each,up to 2 points) Up to 2 Resource pts. 0
4.Replace Toilest with Ultra-Low Flush Toilets
(1 point each,up to 3 points) Up to 3 Resource pts. 0
5.Install Chlorine Filter on Showerhead 1 IAQ/Health pt y=yes 0
6.Convert Gas to Tankless Water Heater 4 Energy pts y=yes 0
7,Install Water Filtration Units at Faucets
(2 points each,up to 4 points) Up to 41AQ/Health pts. 0
8.Install On-Demand Hol Water Circulation Pump 4 Resource pts Y= as 0
r.wecmcer
1.Install Compact Fluorescent Light Bulbs(CFLs)
(6 bulbs=2 points,10 bulbs=3 points,12 bulbs=4 points) Up to 4 Energy pts. 0 •
2.Install IC-AT Recessed Fixtures with CFLs(1 point each,up to
5 points) Up to 5 Energy pts. 0
3.Install Lighting Controls(1 point per fixture,up to 4 points) Up to 4 Energy pts. 0
4.Install High Efficiency Ceiling Fans with CFLs
(1 point each,up to 4 points) Up to 4 Energy pts. 0
1 I I
G.Appliances
1,Install Energy Star Dishwasher 1 Energy pt y=yes 0
2.Install Washing Machine with Water and Energy
Conservation Features 1 Energy pt y=yes 0
3.Install Energy Star Refrigerator 1 Energy pt y=yes 0
4.Install Built-in Recycling Center 3 Resource pts y=yes 0
H.Insulation
1.Upgrade Insulation to Exceed Title 24 Requirements
a.Walls 2 Energy pts y=yes 0
b.Ceilings 2 Energy pts y=yes 0
2.Install Floor Insulation over Crawl Space 4 Energy pts y=yes 0
3.Install Recycled-Content,Fiberglass Insulation with
No Added Formaldehyde 3 IAQ/Health pts y=yes 0
4.Use Advanced Infiltration Reduction Practices 2 Energy pis y=yes 0
5.Use Cellulose Insulation
a.Walls 4 Resource pts y=yes 0
b.Ceilings 4 Resource pis y=yes 0 •
6.Alternative Insulation Products(Cotton,spray-foam)
a.Walls 4 Resource pis y=yes 0
D,Uewngs 4 Resource pts y=yes 0
' mows INPUT Resources Energy IAO/Health
�1.Install Enargy-Efficient Windows
a.Double-Paned 1 Energy pt y=yes 0
i
b.Low-Emissivity(Low-E) 2 Energy pts y--yes 0
Lc_Low.Conductivity Frames 2 Energy pts y=yes 0
2.Install Low Heal Transmission Glazing 1 Energy pt y=yes 0
1 1 1
J.Heating Ventilation and Air Conditioning
F1.Use Duct Mastic on All Duct Joints -----it 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 1 IAO/Health pt y=yes 0
4.Clean all Ducts Before Occupancy 2 IAQ/Health pts y=yes 0
5.Install Solar Attic Fan 2 Energy pts y=yes 0
6.Install Attic Ventilation Systems 1 Energy of y=yes 0
7.Install Whole House Fan 4 Energy pts y=yes 0
B.Install Sealed Combustion Units
a.Furnaces 3 IAQ/Health pts y=yes 0
b.Water Heaters 3 IAQ/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 stoveslnsehs 1 IAQ/Health of y=yes 0
b. Install/Replace Dampers 1 Energy pt y=yes 0
c.Install Airtight Doors 1 Energy pt y=yes 0
14.Install Zoned,Hydronic Radiant Heating 3 Energy pts y=yes 0
15.Install High Efficiency Filter 4 IAQ/Health pts y=yes 0
16.Install Heat Recovery Ventilation Unit(HRV) 51AQ/Health pts y=yes 0
17.Install Separate Garage Exhaust Fan 3 IAQ/Health pts y=yes 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 pis y=yes 0
4.Install Photovoltaic(PV)System
(1.2 kw=6 points,2.4 kw=12 points,3.6 kw=16 points) Up to 16 Energy pts 0
16.Select Safe and Durable Roofing Materials _ 1 Resource pt y=yes 0
7.1 Radiant Barrier 3 Energy pts y=yesi 0
1 1 I
L.Natural Heating and Cooling
1.Incorporate Passive Solar Heating 5 Energy pts y=yes 0
0
2.Install Overhangs or Awnings over South Facing Windows 3 Energy pts . y=yes
3.Plant Deciduous Trees on the West and South Sides 3 Energy pts y=yes 0
• I 1 1
r
INPUT Resources Energy Q
. n oor r ue rty en n s as ,
1.Use Low/No-VOC Paint 1 IAO/Health pts y--yes 0
2.Use Low VOID,Water-Based Wood Finishes 2 IAO/Health pis y=yes 0 •
3.Use Low/No VOC Adhesives 3 IAO/Health 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 61ACJHealth pis y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAO/Health pts y--yes 0
7.Seal all Exposed Particleboard or MDF 4 IAO/Health pts y=yes 0
B.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 IAO/Health pts y=yes 0
1 1 1
N.Flooring
1,Select FSC Certified Wood Flooring 6 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 pis y=yes 0
4,Install Natural Linoleum in Place of Vinyl 5 IAO/Health 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 olntsvat a e. 140[-- 1301 57
Total Points Project Received: 0 01 0 •
G:datalpmgsrgreenbulldngguidelineshemodelersigreenpdnenel2.12.04pro1eoledids
•
Community Development
10300 Torre Avenue
!MV 0
/- Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
OCUPEI�TINO
Building De artment
JOB ADDRESS: (o M v/ 7Q 4- PERMIT # /; (-)Y D v
OWNER'S NAME: r44tr lc , PHONE #
GENERAL CONTRACTOR: 4rw3' r, n �/;,„ FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
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
Tile
� 6
Owner/Contracto lgnature Date