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09010024 CITY OF CUPERTINO BUILDING DIVISION PERMIT NF; � . BUILDING ADDRESS: PERMIT NO. OWNER'S NAME: PERMTT ISSUE DATE _io A CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH a O O LICENSED CONTRACTOR'S DECLARATION lob Description m 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Z u with Section 70(10)of Division 3 of the Business and Professions Code.and my license is o y in full fore and effect.. y g3 ELECTRCL SVC PANL UPGRD TO 2 0 DAMPS 1 0 D Ig Z License Class Lie.R ■ 3 y a Date 6 Contractor 6oatr+�+ L�LtLiL L ARCHITECTS DECLARATION < I understand my plans shall be used as public records �yU 4 O y Licensed Professional y OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors License Law for the C O O following reason.(Section 703 1.5,Business and Professions Code:Any city or county R 2 ff 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 file a signed statement Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation yF$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or y 5§ that he is exempt therefrom and the basis for the alleged exemption.Any violation of 81500 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(M). 35621014 . 00 ❑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 Required Inspections and Professions Code:The Contractors License Law dace not apply to an owner of q P property who builds or improves themn,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(Sec.7004,Business and Professions Code:)The Contractors 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 Contractors License law. ❑I am exempt under Sec. B&P C for this mason Owner Date WORKER'S COMPENSATION DECLARATION hereby affirm under penalty of perjury one of the following declarations: sve and will maintain a Certificate of Consent to self-insure for Workers Compen- :ion,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 Compensation Insurance carrier and Policy number am: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) Of Icsa) I certifv that in the performance of the work for which this permit is issued,I shall not employ any person' manncr � b me subject to the Workers'Compensation Laws of Califo Applicant NOTICE TO ANT:If,after making this Certificate of Exemption,you should become subj&t 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 [moi V2 1 hereby affirm that there is a construction lending agency for the performance of tx> the work for which this permit is issued(Sec.3097,Civ.C.) (rad.Q Lender's Name ]Z Lenders Address U m0 I re certify that I have ad this application and state that the above information is LL+o" cormcL I agree to comply with all city and county ordinances and state laws relating to 0 V building construction,and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. ie (We)agree to save,indemnify and keep harmless the City of Cupertino against ,r lA liabilities,judgments,costs and expenses which may in any way accrue against said City �7 U Z in consequence of the granti g of this permiL Date t"r APPLICANT UNDE NOS AND WILL COMPLY WITH A L NON-POINT Issued by: 6 SOURCE REGUL A N . ° Re-roofs .- Signature of Appl' t/Comractor DateType of Roof I�IAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as dc(incd by the Cupertino Municipal 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. ❑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 pit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. .strict? ❑Yes u 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 cu sly ve a tenant.that it is my responsibility to notify the occupant of the [Owner cyuiremcn mustV be mel prior m issuance era certirrcae aroeeapan Signature of Applicant Date o thodzed agent D,e 04 All roof coverings to be Class'JW'or better CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . . 35621014 . 00 DATE ISSUED. . . . . . . : 01/07/2009 RECEIPT #. . . . . . . . . . BS000006917 REFERENCE ID # . . . : 09010024 SITE ADDRESS . . . . . : 11250 REDONDO CT SUBDIVISION . . . . . . : CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER LESLY HORTA ADDRESS . . . . . . . . . . . 11250 REDONDO CT CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4740 RECEIVED FROM . . . . : GODWIN ELECTRIC CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096 COMPANY TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . . CITY/STATE/ZIP . . . : TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 1, 500 . 00 1. 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 1, 500 . 00 0 . 50 0 . 00 0 . 50 0 . 00 1BUSLIC FLAT RATE 1. 00 114 . 00 0 . 00 114 . 00 0 . 00 1EPERMITFE FLAT RATE 1. 00 40 .79 0 . 00 40 . 79 0 . 00 1ERT<200 UNITS 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 237 . 87 0 . 00 237 . 87 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CASH 237 . 87 --------------- TOTAL RECEIPT 237 . 87 CITY OF CUPERTINO CITY OF CUPEkTINO GENERAL BUILDING PERMIT APPLICATION FORM APN# ' I Q ( Q Date: 7loj Building Address: 112- SO R,C0111 b c'-/-- �����z��,�� �� q Sd ►LI Mailing Address (if different from building address): Owner's Name: Phone#: �� 2 G_ ©� ►I L c S L Y 14 c�R�v9 ��03) Contractor: Phone*oj) F gg Yo 6 S" 6jdb\,.j i ,j CtEcV-iC Fax: .- Contractor License#: 6-I o Cupertino Business License#: Contact: Phone: 8'86 To 6 J Fax: Residential Commercial El Job Description: E �� �2i�,, S C;Z� �� AP EL O P Building Permit Info: / BldgE3 Elect Eg Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B Valuation ' 5-C5,.> Square Footage: V Project Size: Ex ress ❑ Standard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it to the application or if applicable, include in plan set& the sheet index. Points Achieved: For help, contact Build it Green at www.buflditgreeg.org Revised 10/20/08 V�_- CITY OF CUPERTINO cin OF GENERAL BUILDING APPLICATION - CUPEI�TINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windows) 1WINMEWSTR New Window-structural shear B wall/masonry(includes plan ck fee) 1 EPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M 1PLMBLNCK Stand Alone Plumbing Pln Ck(hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B when not over counter) hourly-stand alone 1BSEISMICR Seismic Residential B 1 BSEISMICO Seismic Commercial B 1 TRAVDOC Travel &Documentation B 1BUSLIC Business License B 5 of 5 . n oor Air ua ity and imshes INPUT Resources Energy IA01'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 p 0 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 7.Seal A 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=yesi 0 i 1 1 N.Flooring Li 1.Select FSC Certified Wood Flooring B 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-1 1 Available-1 1 1401 130 57 Total Points Project Received: 0 0 0 Y' t 7 0 l G:datalprogs/greenbuildingguidelinestremodelers/greenpointsfinal2.12.D4protected.xls Community Development 10300 Torre Avenue _ Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 ';UPEI�TINO Building Department JOB ADDRESS: -45-0 t ° d c r _ PERMIT # 0 OWNER'S NAME: LCS L`t 1-1�z-� PHONE # 6' 8 8 8 --5 06 S GENERAL CONTRACTOR: j�L,t=cj R l L FAX # --- I am not using any subcontractors: © 9 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