09010011 CITY OF CUPERTINO Yy�r
BUILDING DIVISION "kt PERMIT V� L� I� '
BUILDING ADDRESS: PERMIT NO.
22384 RAMONA CT UHRI MICHAEL
OWNER'S NAME: PERMIT ISSUE DATE
SA CONTROL NO.
ARCHITECTIENGiNEER: BUILDING PERMIT INFO
RPLC HEATER & ADD /AC BLDG ELECT PLUMB M
ECH
u p C LICENSED CONTRACTOR'S DECLARATION
v firm 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 in full force and effect.
IR? License Class Lic.N
'—t F-w DateContractor
ARCHITECTS DECLARATION
�y < I understand my plans shall be used as public records
D,U
Oy Licensed Professional
H OWNER-BUILDER DECLARATION
I hereby affirm that IE.exempt from the Contractor's License Law for the
a 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 yy prior to its issuance,also requites 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
y. (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 any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(SSW).
❑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 Contractor's License Law does not apply to an owner of fl 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.).
51i
1as owner of the property,am exclusively contracting with licensed contractors to
consruct 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 conuacts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under S c. B&P C for this reason
Owner Date
WORKEWYCOMPENSAT19N 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-
.,ation,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 Workees Compensation Insurance carrier and Polity number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for anc 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 sspp as to become subject to the Workers Compensation
Laws of California.Date - /r
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"' CONSTRUCTION LENDING AGENCY
E r►�-t I hereby affirm that there is a construction lending agency for the performance of
a 5 the work for which this permit is issued(Sec.3097,Civ.C.)
W�,Q Lender's Name
]Z Lender's Address
U 0 I certify that I have read this application and state that the above information is
LL" correct.I agree to comply with all city and county ordinances and state laws relating to
C V building construction.and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
PA (We)agree to save,indemnify and keep harmless the City of Cupertino against
„Hy 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. Date
1"4 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REG LATIgNS.
/1 P S_ U Re-roofs
Signature of Applicantl ntractor Data T 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.
❑Yu 02il'i
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
it hazardous air contaminants as fined by the Bay Area Air Quality Management all new materials for inspection.
-.striet7
❑Yes No
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 tenon that itis my responsibility to notify the occupant of the
requirements hick m be t prim issuance of a certificate of Occupancy. Signature of Applicant Date
r autAll roof coverings to be Class'n"or better
Owner ohorized a t Dam
CITY OF CUPERTINO
6 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 # . . . : 09010011
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 4, 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 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 286 . 04 0 . 00 286 . 04 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 392 . 60 VISA
---------------
TOTAL RECEIPT 392 . 60
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
CITY OF CUPERTINO
FURNACE/AC C) 7
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:.l 1
�C{m Ung.
Owner's Name. Phone#:
Contractor: Phone#:
Fax#:
Contractor License#: Cupertino Business License#:
Contact: Phone#:
Fax #:
Building Permit Info:
Elect 9 Plumb ❑ Mech ❑
Residential 14 Commercial
Job Description:
For Residential Installations:
Attic ❑ 1 sc floor [� 2nd floor ❑
Adhere to minimum setback requirement LJN
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural c_alcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction(Usage Class):
�� ►% . �J T�
Strapped ❑ On Platform ❑ Bonded K'— New Location Replacement
Project Size: Express ❑—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 6/16/08
CITY OF CUPERTINO
FURNACE/AC
CUPEkT1NO FEE SCHEDULE
Group
AIR FURN/AC
CONDITIONING
1BCAIRHAN Commercial A/C Units <= IOk CFM B
1MCRAA Commercial Mech Repair/alt/add M
1BSEISMICO Seismic Commercial B
1PGASCOM Commerical for ea gas piping System P
1-4 outlets
1PGASRES Residential for ea gas piping system P
of 1-4 Outlets
1BPGAS For each gas piping system of 5 or P
more per outlet. CommfResid
1 BREMAIRHAN Residential A/C units <= l Ok CFM B
1MRRAA Residential Mech Repair/alt/add M
I 1BSEISMICR Seismic Residential B
lEPERMITFEE Electric Permit E
1MPERMITFEE Mechanical Permit M
1 PPERMITFEE Plumbing Permit P
1TRAVDOC Travel Documentation B
1BUSLIC Business License B
M.Indoor it uality and Finishes INPUT Resourres Energy
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 aM 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
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 Rapify 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: 1401 1301-----5-71
Total Points Project Received: 01 01 0
G:data/progs/greenbuildingguidelines/remodelers/greenpointsfinal2.12.D4protected.xis