09010008 CITY OF CUPERTINO
BUILDING DIVISION PERMIT lr� laJL�RI ' ?R4Tc� *
BUILDING ADDRESS: PERMIT NO.
22384 RAMONA CT UHRI MICHAEL A 9010008
OWNER'S NAME: PERMIT ISSUE DATE
yRT UTCRAF61=1 AGT SA Y5"2999 CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
INSTL TNKLS WATER HEATER BLDG ELECT PLUMB MECH
D O D D
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
Z H in full force and effect.
2 License Class Lie.N
F,a Date Contractor
g r ARCHITECTS DECLARATION
a< I understand my plans shall be used as public records
D,u
4 O H Licensed Professional
y 3 OWNER-BUILDER DECLARATION
I hereby affirm that I 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
K$ which requires a permit to construct,alter,improve,demolish,or repair any structure
Z prior to its issuance,also requires the applicant for such permit to file a signed statement
_G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
Y.t— (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
Section 7031.5 by arry applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500).
❑I,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 Contractorse License Law dors 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.).
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 conuactor(s)licensed pursuant to the Contractors
License Law.
❑1 am exempt under S e .B&P C for this reason
Owner Dare
WORKER'S C MPENSATIO 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 Workers Compen-
...tion,as provided for by Section 3700 of the Labor Code,for the performance of the
work 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 Workers Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleted if the permit is for one hundred dollars($100)
or Iess.)
I certify that in the performance of the workforwhich this permit is issued,I shall not
employ any person in any rjcct to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.4 ter makini4is 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 RCONSTRUCTION LENDING AGENCY
[~i C.,) I hereby strum that there is a construction lending agency for the performance of
tx> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
z Lenders Address
U C) I certify that I have read this application and state that the above information is
LL,r" correct.1 agree to comply with all city and county ordinances and state laws relating to
0 V construction.building consction.and hereby authorim representatives of this city to enter upon the
W above-mentioned property for inspection purposes
LL (We)agree to save,indemnify and keep harmless the City of Cupertino against
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 UN ST NDP AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGUL ONS.
— �ru Re-roofs
Signature of Applicam/Contrakyr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
az defined by the Cupertino Munici 1 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.
[3 Yes No
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
tit hazardous air contaminants azfind by the Bay Area Air Quality Management all new materials for inspection.
rstrict?
❑Yes u
I have read the ha72rdfts materials requirements under Chapter 6.95 of the Califor.
nia Health&Safety Code,Sc a 25 5,25533 and 25534.1 understand that if the building
docs not curie fly have a t�it is my ponsibility to notify the occupant of the
requirements hich must be et to iss ee of certificate er Occupancy. Signature of Applicant Date
.
Owner or authan nt -S__
ateU All roof coverings to be Class'tJ�"or better
CITY OF CUPERTINO
4 ITEMS OF 10 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . . 35701065 . 00
DATE ISSUED. . . . . . . : 01/05/2009
RECEIPT #. . . . . . . . . . BS000006901
REFERENCE ID # . . . : 09010008
SITE ADDRESS . . . . . . 22384 RAMONA CT
SUBDIVISION . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : UHRI MICHAEL A
ADDRESS 22384 RAMONA CT
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2733
RECEIVED FROM . . . . : MICHAEL A UHRI
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : UHRI MICHAEL A
ADDRESS . . . . . . . . . . . 22384 RAMONA CT
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2733
TELEPHONE . . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 1, 200 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 .79 0 . 00 40 . 79 0 . 00
1PRWHEATR UNITS 1. 00 24 .48 0 . 00 24 .48 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 106 . 56 0 . 00 106 . 56 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform:
A. !/ All the work authorized by this permit
B. _ A portion of the work
C. None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
performed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information(reverse side
Property Owner's Signature: Date:
Job Address: y �� C { �n �r� C-3 Permit#
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
CITY OF CUPERTINO oq
WATER HEATER
CUPEkTiNO PERMIT APPLICATION FORM
APN # f, Date:
Building Address:
Owner's Name: Phone #:
Contractor: Phone #:
w,g
Fax #:
Cupertino Business License #: Contractor State License #:
Contact: Phone #:
Fax #:
Building Permit Info:
Bldg [D,. Elect D-- PlumbMech []---
LN
Residential ] Commercial ❑
Job Description:
Strapped ❑ On Platform ❑ Bonded New Location Replacement ❑
Valuation (cost of project):
Project Size: Express fR Standard ❑ 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 achieved:
Revised 6/16/08
M.Indoor Air Qua rty an rnrshes INPUT ReSDUrCeS Energy IAD/Health
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
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
1 1
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
S.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: 1 1401 130 57
Total Points Project Received: 0 01 0
G:data/progs/greenbuildingguidelines/remodelers/greenpointsfinal2.12.o4protected.xis
Community Development
10300 Torre Avenue
as
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
#TPEkTINO
Building Department
JOB ADDRESS:, PERMIT #0 r6e-"00/7�
OWNER'S NAME: PHONE # Ct o e-
GENERAL CONTRACTOR: FAX#
I am not using any subcontractors: LIC,4
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/Con ctor Signature Date