09010048 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ` ` ' .;
.. .-....
:: .
PERMIT NO.
BUILDING ADDRESS:
1 I PERMIT ISSUE DATE
OWNER'S NAME:
*AT- 4223 vERE)iE3R±s e±RA CONTROL NO.
408) 894-9072
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
J0 p LICENSED CONTRACTOR'S DECLARATION Job Description
V I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business and Professions ode.and my license is FURNACE RE P LC MNT
'+ y in full force and eff i
License Class Lic•k
F Dam Contractor
ARCHITECTS DECLARATION
< I understand my plans shall be used as public records
Oy Licensed Professional
N 3 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
i p o 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
y Z i prior to its issuance,also requires the applicant for such permit to file a signed statement $q.Ft.Floor Area Valuation
< that he is licensed pursuant to the provisions of the Contractor's license law(Chapter 9
F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y
5—2 that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mote than five hundred dollars($500)• 32643077 . 00
❑T,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
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.U,
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(See.7044,Business and Professions Cork:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves themon,and,
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec. B&P C for this reason
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-insure for Workers 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 Workers C hpensation Insurance carrier and Policy number are:
Carrier. Policy No.: WTz 60 l Z,S SJ
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section treed 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 0-4 CONSTRUCTION LENDING AGENCY
E r 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.) ,
W Q Lenders Name
0.Z Lenders Address
U 0 1 certify that I have read this application and state that the above information is
LL E" correct.l agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes
L1. (We)agree to save,indemnify and keep harmless the City of Cupertino against
„Hr liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. Date :'
h"h APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUR EGULATIONS. c._
Le
C/1 z �� Re-roofs - —
Signature of Appiian ontractor DateT Of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
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)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes °
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.
JlalrlCl7 �
❑Yes
1 have mad 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 tate occupant of the
rcyui ts which�agcnt
issuance ora cenificato err ca Signature of Applicant Date
t C2 All roof coverings to be Class'J�"or better
Owner or authorizeDam
CITY OF CUPERTINO
7 ITEMS OF 14 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 32643077 . 00
DATE ISSUED. . . . . . . : 01/12/2009
RECEIPT # . . . . . . . . . . BS000006950
REFERENCE ID # . . . : 09010048
SITE ADDRESS . . . . . : 10599 NATHANSON AVE
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER NATARAJ
ADDRESS 10599 NATHANSON
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1330
RECEIVED FROM . . . . : YIU-HANG LEE
CONTRACTOR MICHAEL LEE LIC # 28867
COMPANY SANDIUM
ADDRESS 4223 VERDIGRIS CIR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95134
TELEPHONE . . . . . . . . : (408) 894-9072
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
1BSEISMICR VALUATION 5, 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1MPERMITFE FLAT RATE 1 . 00 40 .79 0 . 00 40 .79 0 . 00
1MRRAA UNITS 1 . 00 61 . 19 0 . 00 61 . 19 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 225 . 85 0 . 00 225 . 85 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 451. 90 VISA
---------------
TOTAL RECEIPT 451. 90
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
Oq �
CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
�0
Building Address: � i 1 Q_( ( �� AV
Owner's Name: . Phone#: a -73 4-3 33
Contractor: Phone#: g l 4-� To72.
Fax#:
Contractor License#: Cupertino Business License#:
Contact: Phone#: 4� 0 $>71
1 ! `t� Fax #:
Building Permit Info:
Elect L)" Plumb �' Mech
Residential Commercial
Job Description:
For Residential Installations:
Attic ❑ I"floor�� 2°d floor ❑
Adhere to minimum setback requirement ❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Const tion (Usage Class):
C>oOD
Strapped R On Pl tform Bonded New Location ❑ Replacement
Project Size: Ex ress Standard ❑ Lar e ❑ Major❑
Valuation:
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.
Revised 01/07/09
CITY OF CUPERTINO
K ' FURNACE/AC
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1MRAPPVNT Residential for the install/relocate/or M
replacement of ea appliance vent
install ¬ incl in an ap 1 permit.
FURNACE FURN/AC
IPGASRES Residential for ea gas piping system of P
1-4 Outlets
1BPGAS For each gas piping system of 5 or P
more per outlet.
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Residential Seismic B
I 0 �� P N
1 MECPLNCK Mechanical Plan Check M
IMFR=<100 Furnace Syst<=100k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance up to and
include 100,000 Btu/h
1 MFRN>100 Furnace Syst> 100k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance over
100,000 Btu/h
I EPERMITFEE Electric Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
1PPERMITFEE Plumbing Permit P
I TRAVDOC Travel Documentation B
1BUSLIC Business License B
i
INPUT Resources EnLrgy AD
M. n oor it ua iry an Frnrshes
1.Use LowMo-VOC Paint 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3.Use Low/No 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.Seal all Exposed Particleboard 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 t
N.Flooring
1.Select FSC Certified Wood Flooring 8 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 1 1
Total Points Available: I 14OF 1301 57
Total Points Project Received: 01 01 0
G:data/progs/greenbuildngguidelines/remodelers/greenpointsfinalL I2.04protected.xis
Community Development
10300 Torre Avenue
} Cupertino CA 95014
' . Telephone(408)777-3228
CITY OF Fax(408)777-3333
:UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
10 S9 07 oaut'.,sw. A;JL/-t - '
00
OWNER'S NAME: Omba
PHONE # 6/o 2
GENERAL CONTRACTOR: FAX#
I am not using any subcontractors: `. -z-
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
Owner/Contractor Signature Date