09010120 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
10126
OWNER'S NAME: PERMIT ISSUE DATE
osi0 : S A CONTROL NO.
T.T
408) 292-9938
ARCHITECT(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a 0 a o
u p p LICENSED CONTRACTOR'S DECLARATION
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is
=y infullforceandeffect RMDL KTCHN & SHOWER STALL REPLACMENT-NO RE-RF &
j rM Y License Cl Lic.g
r—c Dam Contractor Jft— NO STRUCTRL
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
�yU
4u.H Licensed Professional
n y OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
p o following reason.(Section 7031.5,Business and Professions Code:Any city or county
which'mquires a permit to construct,alter,improve,demolish,or repair any structure
y Yy 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
F $ (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or
y .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of 815000
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500).
El 1,as owner of the property,or my employees with wages as their sole compensation, 34242011 ' 0 0
will do the work and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
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
sake.).
❑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 conuacmr(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec B&P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of pequry one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
,on,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 Insurance carrier and Policy number arc:
Cartier. M 1,t[6YP Policy No.: �
CERTIFILTATE OF EXEMPTION FROM RKERS'
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 Workers'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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z R CONSTRUCTION LENDING AGENCY
[��+ I hereby affirm that there is a construction lending agency for the performance of
f3ithe work for which this permit is issued(Sec.3097,Civ.C.)
fsaf�.o--4
Lender's Name
►7 Lendees Address
U 0 1 certify that I have read this application and state that the above information is
VJ cored 1 agree to comply with all city and county ordinances and state laws relating to
OFbuilding construction,and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
o..4 to liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-P NT Issued by: Date
SOURCE REGULATIONS. c,
• D I Re-roofs
Signature of A icant/Contractor 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.
❑Yes XNo
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
't hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
rict?
❑Yet
1 have read the hazardous 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
requirements which ust be poor to issuance of a Certificate of Occup err.I Signature of Applicant Date
O All roof coverings to be Class"ror better
Owner or authori d agent Date
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 34242011 . 00
DATE ISSUED. . . . . . . : 01/28/2009
RECEIPT #. . . . . . . . . BS000007061
REFERENCE ID # . . . : 09010120
SITE ADDRESS . . . . . : 10126 LAMPLIGHTER SQUARE BLVD
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER CALVERT BEVERLY H AND DENNIS W
ADDRESS 10126 LAMPLIGHTER SQUARE BLVD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : ROCK SOLID BUILDERS
CONTRACTOR . . . . . . . : JAY G. HAMMEN LIC # 29304
COMPANY ROCK SOLID BUILDERS
ADDRESS 918 HARLISS AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95110
TELEPHONE . . . . . . . . : (408) 292-9938
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 15, 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BPFIXTURE NO OF FIXTURE 3 . 00 24 .48 0 . 00 24 .48 0 . 00
1BSEISMICR VALUATION 15, 000 . 00 1 .50 0 . 00 1 . 50 0 . 00
1BUSLIC FLAT RATE 1 . 00 114 . 00 0 . 00 114 . 00 0 . 00
1PPERMITFE 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 222 . 56 0 . 00 222 . 56 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CASH 222 .56
---------------
TOTAL RECEIPT 222 .56
CITY OF CUPERTINO
ADDITION/REMODEL
CUPEkTINO PERMIT APPLICATION FORM
APN 3q,� oo# Date:
Building Address:
Mailing Address (if different from building address):
Owner's Name: Phone
e xiCA Li c 2 6 5_0 ' 2
Contractor: Phone#: 'log (--/gg
-
G IV � t, � _ Fax#:
Contractor License#: SLO
Cupertino Business License#: 0�
Contact: Phone#: jvqS
=_ l
Pv M f3,J b e ol Fax #:
Building Permit nfo:
Bldg. ❑ Elect. ❑ Plumb. ❑ Mech. ❑ Hillside ❑
Job Description:
Addition-What is being added?(Be Specific): �1 �' c c i-� c� hb N r l til C�
What is being remodele (not including addition)?
V k 1-(-)4 clJ 1-H010C✓: ',-)—IA),L
Remodel Includes Re-Roof. Yes ❑ No/M If yes list number of squares
Remodel Includes Structural: Yes ❑ No R
Do you have the pre-application planning approval? Yes ❑ No ❑
If yes, please provide a copy of your planning approval letter. Planners name:
Square Footage:
Addition: Porch: Deck: Garage: Detached Attached
Remodel: Kitchen__Jp Bath__ Other
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B II/III/V-A ❑ II/III B, IV-HT,V-B ❑— V "-3
Valuation: /5- Doc) Please check this box if the project is a
second-story addition ElProject Size: Express EJ Standard ❑ Large F] Major❑
Please complete relevant portion of the Green Building
Checklist& attach it to the application or if applicable, Green Building Points Achieved:
include in plan set& the sheet index.
***For Office Use Only***
Over-the-Counter ❑ Revised 01/07/09
CITY OF CUPERTINO
ADDITON/REMODEL
FEE SCHEDULE
Quantity Fee ID Fee Description Fee Group Permit Type
Sq Ft
1 REMRES2 Remodel Residential B
Greater than 1000 sq ft
1REMRES3 Remodel Residential B
Greater than 2500 sq ft.
1REROOFRES Residential Re-roof Each B
100 SF
REMODEL PLNCK
1 STPLNCK(1-3 for Standard Plan Check B NOT FOR OVER THE
remodel) COUNTER PLAN CKS.
WINDOW/SLIDING 1R3SFDREM
GLASS DOOR
1 WINREP Replacement windows B
(ea 8 windows)
1 WINNEWNSTR New Window (non- B
structural)
1 WINMEWSTR New Window (Structural B
Shear Wall/Masonry)
1 WINBAYSTR Bay Window (Structural) B
SKYLIGHTS 1R3SFDREM
1 SKYL<10 SF Skylight less than 10 sf B
1 SKYL>10SF Skylight greater than 10 B
sf or structural
1STAIRS Stairs-first flight/ea addt'l B
1 EPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
/ 1PPERMITFEE Plumbing Permit Fee P
1 ELCPLNCK Stand Alone Electric Pln E
Ck (hourly)
CITY OF CUPERTINO
ADDITON/REMODEL
FEE SCHEDULE
Quantity Fee ID Fee Description Fee Group Permit Type
Sq Ft
1MECPLNCK Stand Alone Mechanical M
Pln Ck(hourly
IPLMPLNCK Stand Alone Plumbing P
Pln Ck (hourly)
IBCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fee
IBSEISMICRE Seismic Residential B
J
VDOC Travel &Documentation B
IBUSLIC Business License B
Ij
M.In oor Air Quality and Finishes
1.Use LOwNl VOC Paw 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3.Use Lowft VOC AdheSives 3 IAQ/Health pts Ayes 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.Seal all P i w 4 IAQ/Health. pts y=yes 0
S.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/Hsalth pts y=yes 0
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring a 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
i 1 1
Total Points Available: 1401 130 57
Total Points Project Received: A0 --OF 0
� p
G:data/progs/greenbuilcongguidelines�remodeiers/greenpointsfina1212.04protected.xis
t
q,
166"
_3 11
31
1514
36' � 36' 42 33'
84
---- 331
4 48
3,,
14-2'
36"
36" 36 18" 24'
W3630 W4230 W3330
A
77---
C� --j---R
7i B36 7B3Dl8 24.DISHW BHFC36LS
, 77
7
i W3612
.2 Vr-A-
Cft
WE W"
DFIS AND
)4
rj*
kV or 77-atiOns...Ailljjs,��'
to S and i
-7jdt
IS fir,
he O-L alt4p�
u "n
T
Wldiiw oce,Ssion fr&,) CD) B�Gcs 0
:HALL IVOPI
CS LAA OCCUA
a6eMO be Or Z OV\A
any -A
>=
4Z
..69
oc
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
`M TINO
Building Department
JOB ADDRESS: PERMIT #
l OI , C l -r2 O Zt 21?
OWNER'S NAME: J>r4oj C-q r-kr PHONE # 4 Ji
GENERAL CONTRACTOR LLC tix _�oj L1 c,2 S 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
11-'-0L- /Co
r 7or Signature Date