09010123CITY OF CUPERTINO
BUILDING DIVISION PERMIT
T
i�� T1io.N�
BUILDING ADDRESS:
PERMIT NO.
10500 MADERA DR
CUPERTINO PL
OWNER'S NAME:
PERMIT ISSUE DATE
>N
S A CONTROL NO.
(408)253-0618
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of The Business and Professions Code, and my license is
in full force and effegL/ `
License Class �- ' -S �+ Lic. hY LnV -
COPPER RE-PIPE/WATER MAIN
Date ( - 2 �Contractor
ARCHITECTS DECLARATION Q
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$5000
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occu e e
an
Occupancy TYP
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
32635052 . 0 0
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
willdo 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
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.).
❑ I, 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 contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under See. B & P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insum 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.
[:11 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 Workees Compensation Insurance carrier and Policy number are:
Carrier. ``4'r)Z f (_Policy No.: u E .�—
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, 1 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
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
1 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, indemnify and keep harmless the City of Cupertino against
\
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
l
APPLICANT UNDERSTANDS AND WILL COMP Y WITH ALL NON -POINT
Issued by: ate
SOURCE REGULATIONS.
Re -roofs 1
1
Type of Roof
Signature of Applkant/Contraotor— " Date
HidARDOUS MATERIALS DISCLOSURE
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)?
r.'
All roofs shall be inspected nor to an roofing material installed.
P prior Y g
❑Y� ca
Will the future building occupant equipment or devices which
If a roof is installed without first obtaining an inspection, I age a to r move
applicant or use
it hazardous air contaminants as defncd by the Bay Arca Air Quality Management
all new materials for inspection.
�tstnct?
❑ Yes ❑ Nu
I have read the hazardous materials requircments under Chapter 6.95 of thc Califor-
nia Health & Safcty Codc, Sections 25505.25533 and 25534.1 understand that if the building
docs not currentltave a ten my responsibiliy to notify the occupant of the
requirements w hch mttst pri issuance � 2tflt Peca""-y-'
Signature of Applicant Date
All roof coverings to be Class "`r or better
Date
owner or aulSorized agent`
7 ITEMS OF 7
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 32635052.00
DATE ISSUED.......: 01/28/2009'
RECEIPT #......•••: BS000007064
REFERENCE ID # ...: 09010123
SITE ADDRESS .....: 10500 MADERA DR
SUBDIVISION .......
CITY CUPERTINO
IMPACT AREA .......
OPERATOR: patg
COPY # : 1
OWNER ............:ANDERSON THOMAS W AND GAIL L
ADDRESS 10500 MADERA DR
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-1136
RECEIVED FROM ....: FRANK L CARDIA
CONTRACTOR .......: CARDIA, FRANK L LIC # 612
COMPANY CUPERTINO PLUMBING
ADDRESS ..........: 1300 DELL AVE STE C
CITY/STATE/ZIP ...: CAMPBELL, CA 95008
TELEPHONE (408)253-0618
FEE ID
UNIT
QUANTITY
AMOUNT
PD -TO -DT
THIS REC
NEW BAL
----------
----------
1BCBSC
-------------
VALUATION
----------
5,000.00
----------
1.00
----------
0.00
----------
1.00
0.00
1BPFIXTURE
NO OF FIXTURE
9.00
73.44
0.00
73.44
0.00
1BPWATER
UNIT
1.00
40.79
0.00
40.79
0.00
1BSEISMICR
VALUATION
5,000.00
0.50
0.00
0.50
0.00
1PPERMITFE
FLAT RATE
1.00
40.79
0.00
40.79
0.00
1PRREPIPE
NO OF FIXTURE
1.00
10.20
0.00
10.20
0.00
1TRAVDOC
FLAT RATE
1.00
40.79
0.00
40.79
----------
0.00
----------
TOTAL PERMIT
----------
207.51
----------
0.00
207.51
0.00
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT :
AMOUNT
---------------
207.51
---------------
207.51
REFERENCE NUMBER
--------------------
MC
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
301 ROUGH PLUMBING 507 FINAL PLUMBING
, SM
CITY OF
CUPEkTINO
CITY OF CUPERTINO r� p
REPIPE/SEWER/MAIN SERVICE
PERMIT APPLICATION FORM
V
2�
APN #
Date:
Building 'Address:-
Fee
+�
0 Sc
Owner's Name:
Phone #:
Group
Cont ctor:
Phone #:
Commercial building
Fax #:
Contact.
Phone #: 36
Fax #:
Contractor License #:
Cupertino Business License #:
1BPREPIPE
Job Description:
P
1CPRP
Residential - Commercial ❑
Valuation:
P
Project Size: Express Standard 0 Large Major
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index.
Green Building Points:
Quantity
Fee ID
Fee Description
Fee
Permit Type
Group
1PCSEWER
Commercial building
P
1CPSS
sewer/sanitary sewer
r
1BPREPIPE
Commercial re -pipe per fixture
P
1CPRP
1PGASCOM
Commercial Gas Piping System
P
_
1-4 Outlets
1BCBSC
Cal Bldg Standards Commission
B
ALL PERMIT
Fee
TYPES
1BSEISMICOM
Seismic Commercial
P
Revised 01/07/09
1. Use LowlNo-VOC Pah
1 IAQ/Health pts
y --yes
2. Use Low VOC, Water -Based Wood Finishes
2 IAQ/Health pts
y=yes
3. Use LowlNo VOC Adhesives
3 IAQ/Health pts
y=yes
4. Use Salvaged Materials for Interior Finishes
3 Resource pts
y=yes
5. Use Engineered Sheet Goods with no added Urea
4 Resource pts
y=yes
Formaldehyde
61AQ/Health pts
pyes
6. Use Exterior Grade Plywood for Interior Uses
1 IAQ/Health pts
y=yes
7. Seal all Exposed P card or MDF
4 IAQ/Health. pts
y=yes
B. Use FSC Certified Materials for Interior Finish
4 Resource pts
y=yes
9. Use Finger -Jointed or Recycled -Content Trim
1 Resource pts
y=yes
10. Install Whole House Vacuum System
3 IAQ/Health pts
y=yes
N. Flooring
1. Select FSC Certified Wood Flooring
a Resource pts
y=yes
2. Use Rapidy Renewable Flooring Materials
4 Resource pts
y=yes
3. Use Recycled Content Ceramic Tiles
4 Resource pts
y=yes
4. Install Natural Linoleum in Place of Vinyl
5 IAQ/Health pts
y=yes
5. Use Exposed Concrete as Finished Floor
4 Resource pts
y=yes
6. Install Recycled Content Carpet with Low VOCs 4 Bowrw 11 1711,
Total Points Available:
Total Points Pro'ect Received:
:F401 130 57
01 01 0
G:data/props/greenbuilcgngguidelineshemodelers/greenpointsfinal212.04protected.xls
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Buildin De artmen
PERMIT #
JOB ADDRESS: D j l�/ 2 3
/� 5Ud Mly PHONE# Z9S-- 2-47
OWNER'S NAME: C I "''"5 r+oso✓` FAX #
GENERAL CONTRACTOR:
i 2 - O�P
I am not using any subcontractors: Date
ignature
Please check a
Date
Owner/ Contractor Signature