09010068 CITY OF CUPERTINO
BUILDING DIVISION PERMITMQ � «'
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: PERMIT ISSUE DATE
S AW891CONTROL NO.
408 437-2442
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
o p LICENSED CONTRACTOR'S DECLARATION Job Description
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing p
Z t, with Section 7000)of Division 3 of the Business and Professions Code.and my license is
°=y in full force and effect. HVAC, RPLC EXTNG 3TON _HEATPUMP W/CONDENSR
4 License Class Lic.N
F
in Date^/-/ Contractor U
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
a
L p y Licensed Professional
y OWNER-BUILDER DECLARATION
t 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
i C O following reason.(Section 7031.5,Business and Professions Code:Any city or county
K$Pi which requires a permit to consuuct,alter,improve,demolish,or repair any structure
y^� prior to its issuance,also requires the applicant for such permit to file a signed statement
E Em that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
Y.
F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of 5224
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number QCCu
not more than five hundred dollars(5500). 36944018 . 00
Occupancy
Type
❑1,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
and Professions Code:The Conuactoes 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
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 U.
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 Contractors
License Law.
❑I am exempt under Sec B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
_-tion,as provided for by Section 3700 of the Labor Code,for the performance of the
wort for which this permit is issued.
❑1 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 am:
Carrier-T�rl1e L �Policy Nd99 2 7l
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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
y
" c CONSTRUCTION LENDING AGENCY
►-� I hereby affirm tut there is a construction lending agency for the performance of
:9> the work for which this permit is issued(Sec.3097,Civ.Q
4 ALender's Name
1. Lender's Address
Q I certify that I have read this application and sure that the above information is
correct.I agree to comply with all city and county ordinances and sure laws relating to
D V building construction,and hereby authorize representatives of this city to enter upon the
H W above-mentioned property for inspection purposes
y LL (We)agree to save,indemnify and keep harmless the City of Cupertino against
y cn liabilities,judgments,toss and expenses which may in any way accrue against said City
Z in consequence of the granting of this permit. y
—r APPLICA NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b : L
SOUR EG CATION Date
Re-roofs
Sign re of Applicanr/Conuactor 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)?
Cl Yes )V No All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant or future building occupant use If a roof is installed without first obtaining an inspection,I agree to remove
pp g p equipment or devices which
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
;trio?
❑Yes �fNo
I haw read the hazardous materials requirementsunder Chapter 6.95 of the Califor-
nia Health&Safety Codc,Sections 25505.25533 and 25534.1 understand that if to building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requnircts hich must met prior to issuance of a Certificate of Occupancy.
������:� � Signature of Applicant Date
All roof coverings to be Class"A"R'`'or better
Ow�ncr or authorized agent Date g
CITY OF CUPERTINO
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN 36944018 . 00
DATE ISSUED. . . . . . . : 01/15/2009
RECEIPT #. . . . . . . . . . BS000006978
REFERENCE ID # . . . : 09010068
SITE ADDRESS . . . . . : 20276 PACIFICA DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER PETE KALNAY
ADDRESS 20276 PACIFICA DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3014
RECEIVED FROM . . . . : DANIEL THOMAS
CONTRACTOR . . . . . . . : TROY COOPER LIC # 26734
COMPANY . . . . . . . . . . : COOPER BROTHERS, INC.
ADDRESS 2151 DEL FRANCO ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95131
TELEPHONE (408) 437-2442
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 5, 224 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 5, 224 . 00 0 . 60 0 . 00 0 . 60 0 . 00
1EPERMITFE FLAT RATE 1. 00 40 .79 0 . 00 40 . 79 0 . 00
1MPER.MITFE FLAT RATE 1 . 00 40 .79 0 . 00 40 .79 0 . 00
1MRRAA UNITS 2 . 00 122 . 38 0 . 00 122 . 38 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 287 . 14 0 . 00 287 . 14 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 287 . 14 AMEX
---------------
TOTAL RECEIPT 287 .14
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
)q C. uv t�
CITY OF CUPERTINO
FURNACE/AC
Off OF
CUPEkTINO PERMIT APPLICATION FORM
APN # 3Ll Ll O I �` c Date:
Building Address:
Owner's NamePhone#:
d�eke el-73
Contractor: Phone#: ,
Vii' / �1f Fax#:
Contractor License#: Cupertino Business License#:
7( -lam'7 31 V
Contact: Phone#: u -6 yq,
Fax #: &
Building Permit Info:
Elect Pj--- Plumb Mech
Residential Z Commercial ❑
Job Description:
For Residential Installations:
Attic ❑ 1St floor ® Ole'!4— 2nd 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 Construction(Usage Class):
Strapped El On Platform 11 Bonded New Location Replacement
Project Size: Express 2---Standard ❑ Large ❑ 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
FURNACE/AC
OF
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1 MRAPPVNT Residential for the install/relocate/or M
replacement of ea appliance vent
install ¬ incl in an a pl permit.
FURNACE FURN/AC
1 PGASRES Residential for ea gas piping system of P
1-4 Outlets
1 BPGAS For each gas piping system of 5 or P
more per outlet.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Residential Seismic B
1 MECPLNCK Mechanical Plan Check M
I pry
1MFR=<100 Furnace Syst<=100k BTU install or M
relocate ea forced-air/gravity type
furnace/bumer, incl ducts/vents
attached to such appliance up to and
include 100,000 Btu/h
1MFRN>100 Furnace Syst> 100k BTU install or M
relocate ea forced-air/gravity type
fumace/bumer, incl ducts/vents
attached to such appliance over
100,000 Btu/h
r 1 EPERMITFEE Electric Permit Fee E
r 1 MPERMITFEE Mechanical Permit Fee M
f 1 PPERMITFEE Plumbing Permit P
1TRAVDOC Travel Documentation B
1 BUSLIC Business License B
INPUT Resources Energy IAD/Health
. n dor rr uality an ims es
1.Use Low/No-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
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7.Seal all Exposed Particleboard or MDF 4 IAQ/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 IAQ/Health pts y=yes 0
1 1 1
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 Avai a e: I i-401 130 57
Total Points Project Received: 0 0 0
G:data/progstgreenbuildngguidelinestremodelers/greenpointsfinal2.12.04proiected.xls
Community Development
10300 Torre Avenue
a{ ,
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
-'UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
Pc1641 1;1
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: FAX # p - (� - ✓/D
Ir
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
Owner/Contractor Signature Date