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09010134 CITY OF CUPERTINO J(^Tr p. BUILDING DIVISION PERMITlr�NT 111�� BUILDING ADDRESS: PERMIT NO. 10436 AVENIDA LN TBD - TO BE DETERMINED 09010134 OWNER'S NAME: PERMIT ISSUE DATE E. A CONTROL NO. ARCHITEC(ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH O p LICENSED CONTRACTOR'S DECLARATION Job Description m I hereby affirm that I rim licensed under provisions M Chapter 9(commencing et z with Section 70()01 otDivision 3 of the Business and Professions Code.and my license is 12 5 AMP MN SVC PANL RE PLMNT **WE S TEC ELECTRIC PD et-<Q. in full force and effect 1 Z License Cl s Co- c Date J-�i ,G 0. contracwr••s a BUS LIC 1/30/9 ARCHITECTS DECLARATION C-C_F,e9ejG I understand my plans shall be used as public records �yU WH Licensed Professional n H< OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the c O following reason.(Section 703 t.5,Business and Professions Code:Any city or county K S which requires a permit to construct,alter,improve,demolish,or repair any structure Zy prior to its issuance,also requires the applicant for such permit to file a signed statement _< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation yF $ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $2200 y that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not more than rive hundred dollars(M)• 34245031 . 00 ❑1,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure is notintendcd or offered forsale(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law does not apply to an owner of q p property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale.If, however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑1.as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a comractor(s)licensed pursuant to the Contractor's License Law. ❑1 am exempt under Sec B&P C for this reason OwnerDate WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: 1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Worker's Compensation Insurrm=carrier and Policy number are: Carriers-PATe-CAM)' Policy No.: 1 0 it CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) 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 Workcrs'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must ,J 0 forthwith comply with such provisions or this permit shall be deemed revoked. z CONSTRUCTION LENDING AGENCY (�� I hereby affirm that there is a construction lending agency for the performance of (Y, 5 the work for which this permit is issued(Sec.3097,Civ.C.) WW Q Lender's Name a z Lender's Address U C) I certify that I have read this application and state that the above information is f7r►" cored I agree to comply with all city and county ordinances and state laws relating to O V building construction,and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. W W (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,judgmcnts,costs and expenses which may in any way accrue against said City /y V Z in consequence of the granting of this permit. Date m"r APPLICANT UNDERST D L COMPLY WITH ALL NON-POINT Issued by: SOURCE REGULATIO �U-Ocl Re-roofs 6i Signature of Applicant/Comractor Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. C]Yes �N5,— Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove At hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes No - 1 have read the hazard materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building does not currently have a tenant.that it is my responsibility to notify the occupant of the requirement ich ust be met prior to r nonce of a Certificate or Occupancy. Signature of Applicant Date +�0 1 1-3 All roof coverings to be Classor better Owner or authorized agent Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 34245031 . 00 DATE ISSUED. . . . . . . : 01/30/2009 RECEIPT # . . . . . . . . . : BS000007080 REFERENCE ID # . . . : 09010134 SITE ADDRESS . . . . . : 10436 AVENIDA LN SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER JUDY BLANKENBERG ADDRESS 10436 AVENIDA LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : PAUL HARVEY CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 2, 200 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 2, 200 . 00 0 . 50 0 . 00 0 .50 0 . 00 1BUSLIC FLAT RATE 1 . 00 114 . 00 0 . 00 114 . 00 0 . 00 1EPERMITFE FLAT RATE 1 . 00 40 .79 0 .00 40 .79 0 . 00 1ERT<200 UNITS 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 237 . 87 0 . 00 237 . 87 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 237 . 87 VISA --------------- TOTAL RECEIPT 237. 87 CITY OF CUPERTINO CITY OF CUPEkTINO GENERAL BUILDING PERMIT APPLICATION FORM APN# Date: Building Address: 10 Lk'x..., G r L v o ,, Mailing Address (if different from building address): Owner's Name: Phone#:a 0-U 0 Y L A N 1C N S3 C� C�5 0� Ll'3-5 O I b Contractor: Phone C(a3 1 S C. Fe4-,Tp-1C-- Fax: (0031 Contractor License#: ca . 5 l TYPE CC- 10) Cupertino Business License#: Contact: ?A\,) L- Adv EY Pho : C�''�1 S (o ro - 60( 00 a Fax: Residential Commercial El Job Description: MAIN /v\A//,j S2 ev 1 G P/�e c, �2P cA �-er�e�.� • �a� � �v� Pte►e� �P -� Building Permit Info: Bldg ❑ Elect ® Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: I-A, 1-B ❑ IUIII/V-A ❑ IUIII B, IV-HT, V-B Valuation. ;-0 0-00 o Square Footage: Project Size: Express tandard ❑ Large ❑ Major ❑ 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.builditgreen.org Revised 01/07/09 uo CITY OF CUPERTINO CIT'°fGENERAL BUILDING APPLICATION CUPEI�TINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windows) 1 WINMEWSTR New Window-structural shear B wall/masonry (includes plan ck fee) 1 EPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck(hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M 1PLMBLNCK 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 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT I TYPES 1BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B 1 TRAVDOC Travel &Documentation B 1BUSLIC Business License B 200 5 of 5 INPUT RL-,CjT Ces Energy 1AD!Health . n oor Arr uality an Finishes 1•.Use LoWNo-VOC ftrd 1 IAQ/Health pts y=yes 0 2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0 3.Use LowMo VOC Adhesives 3 IAQ/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 61AQ/Health pts y=yes 0 0 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 7.Sea]d 5posedPArWabowd or MDF 4 IAQ/Health. pts y=yes 0 8.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 IAQ/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 pts y=yes 0 4.Install Natural Linoleum in Place of Vinyl 5 IAQ/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 i 1 Total Points Available: 401 130 57 Total Points Project Received: , 01 01 0 G:data/progs/greenbuildngguidelines/remodelers/greenpointsfinal2.12.04protected.xls Community Development 10300 Torre Avenue 9x•% Cupertino CA 95014 Telephone(408)777-3228 CITY OF ';UPE�TINO Fax(408)777-3333 Building Department JOB ADDRESS: PERMIT # ,, 10 �-j(� v S N 1 DA L- Iv 0. 01 Of OWNER'S NAME: %M 7 V 9\- (?, l�.N�E/•� e,Q C� PHONE # S 3 C. -(act 00 a. GENERAL CONTRACTOR:WE-STr--e �c_F�c_TR c- FAX # I am not using any subcontractors: L1 -4'�o - d Signature Date Please check applicable subcontractors and complete the following information: 60 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 Owner/Contractor Signature Date