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090100709Op IU Dig �eeF X03 �y�y11H 70.0 SRO ir3= CITY OF CUPEKf11NU BUILD,SNG DIVISION PERMIT BUILDING ADDRESS: OWNER'S NAME: ARCHITECIYENGiNEER: LICENSED CONTRACIUK'S Ubf.LA tAi IVN I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. License Class Lle• t Date Contractor ARCHITECTS DECLARATION I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following rnson. (Section 7031.5, Business and Professions Code: Any city or county 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 that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 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 not more than five hundred dollars (5500). ❑ 1, as owner of the property. or my employees with wages as their sole compensation, will do the work and the strocture is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law don not apply to an owner of property who builds or improves thereon, and who does such wort 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.). coI, as owner of the property, am exclusively contracting with licensed contractors to nstruct 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 contractor(s) licensed pursuant to the Contractor's License Law. ❑ 1 am exempt under Sea B & P C for this mason Owner Date el b WORKER'S CO PEN A77ON 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- aon, 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 Worker's Compensation Insurance carrier and Policy number arc: Carrier. Policy No.. CERTIFICATE OF EXEMPnON FROM WORKERS' COMPENSATION INSURANCE (This section reed 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 manas� bjer,�lo the Workc(s' Cot9PSnsa on Laws of California. Dare �� 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 forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that them is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Cir. C.) Lender's Name L cmices Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorin representatives of this city to enter upon the above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOUR REGU TIONS. �-- 01 Signature of Applicant/Contractor Date HAZARDOUS MATERIALS DISCLOSURE 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)? ❑ Yes IoNo Will the applicant or future building occupant use equipment or devices which it hazardous air contaminants as defined by the Bay Area Air Quality Management trict? ❑ Yes 57No 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 tenant, that it is my responsibility to notify the occupant of the rcyuiremc ¢ nµust be met Pri to issuance of a Ccnificatc of Occupancy. _ gL�11 a i h:s / r Owner or authored agent l5atc Job Description STOVE INSTLTN,SINK INSTLTN& NEW GAS LINE& NEW SWER LINE DRAIN Ft. 35934007.00 Required Inspections a +� .;i Y, Type Issued by: Date f S Re -roofs v Type of Roof All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant Date All roof coverings to be Class 'A" or better PERMIT NO. PERMTr ISSUE DATE A CONTROL NO. BUILDING PERMrrINFO BLDG ELECT PLUMB 0 Job Description STOVE INSTLTN,SINK INSTLTN& NEW GAS LINE& NEW SWER LINE DRAIN Ft. 35934007.00 Required Inspections a +� .;i Y, Type Issued by: Date f S Re -roofs v Type of Roof All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant Date All roof coverings to be Class 'A" or better 7 ITEMS OF 7 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ......... 35934007.00 DATE ISSUED.......: 01/15/2009 RECEIPT #.......... BS000006982 REFERENCE ID # ...: 09010070 SITE ADDRESS .....: 1105 ROLLINGDELL CT SUBDIVISION ....... CITY .............. CUPERTINO IMPACT AREA ....... OPERATOR: patg COPY # : 1 OWNER SANJAY NORONHA ADDRESS ..........: 1105 ROLLINGDELL CT CITY/STATE/ZIP ...: CUPERTINO CA, 95014-5809 RECEIVED FROM ....: SANJAY NORONHA CONTRACTOR .......: LIC # *OWNER* COMPANY ..........: SANJAY NORONHA ADDRESS ..........: 1105 ROLLINGDELL CT CITY/STATE/ZIP ...: CUPERTINO CA, 95014-5809 TELEPHONE ......... FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL ---------- ---------- 1BCBSC ------------- VALUATION ---------- 2,000.00 ---------- 1.00 ---------- 0.00 ---------- 1.00 0.00 1BPFIXTURE NO OF FIXTURE 1.00 8.16 0.00 8.16 0.00 1BSEISMICR VALUATION 2,000.00 0.50 0.00 0.50 0.00 1PGASRES OUTLETS 1.00 61.19 0.00 61.19 0.00 1PLMBINSP HOURS 1.00 122.38 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 ---------- 274.81 ---------- 0.00 ---------- 274.81 ---------- 0.00 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 274.81 --------------- 274.81 VOICE ID DESCRIPTION -------- ---------------------------- 106 SEWER & WATER 301 ROUGH PLUMBING 507 FINAL PLUMBING REFERENCE NUMBER -------------------- VISA VOICE ID DESCRIPTION -------- ---------------------------- 202 UNDERFLOOR PLUMBING 400 SEWER/LATERAL CITY OF CUPERTINO CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE PERMIT APPLICATION FORM D 07 APN #-J' ! 40 (D -7V �C (�� Date: oV���� Building Address: r l RG GL- j N4, >IFLL 6--T- �� t, � �-� N C, Owner's Name: `f N �R � ►� �- A Phone #: Contractor: 0/�j Phone #: �� Fax #: Contact: Phone #: 4 � -7g 1 2_ 2 _ ( 1BPREPIPE Fax #: 6 --f� Contractor License #: Cupertino Business License #: Job Description: .TZ)v e t ►�.1-k is ct aN �1 tJ V. t IAC 'fit-A--r1CAi •- re A4-4.1 P Residential Commercial ❑ Valuation: 4 .2OZ7Z,�) Project Size: Express 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: Quantity Fee ID Fee Description Fee Group Permit Type 1PCSEWER Commercial building sewer/sanitary sewer P 1CPSS 1BPREPIPE Commercial re -pipe per fixture P 1CPRP 1PGASCOM Commercial Gas Piping System 1-4 Outlets P _ 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICOM Seismic Commercial P Revised 01/07/09 1. Use Low/No-VOC Paint 1 IAQ/Health pts y=yes 2. Use Low VOC, Water -Based Wood Finishes 2 IAQ/Health pts y=yes 3. Use Low/No VOC Adhesives 3 IAQ/Health pts y=yes 4. Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 5. Use Engineered Sheet Goods with no added Urea 5 IAQ/Health pts y=yes Formaldehyde 61AQ/Health pts y=yes 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 B. Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 9. Use Finger -Jointed or Recycled -Content Trim 1 Resource pts y=yes 10. Install Whole House Vacuum System 3 IAQ/Health pts y=yes N. Flooring 1. Select FSC Certified Wood Flooring 8 Resource pts y=yes 2. Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 3. Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 4. Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 5. Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 6. Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes Total Points Available: 1 1401 130 57 Total Points Project Received:1 �_ 0 0 0 � " G:data/progs/greenbuildinoguidelines/remodelers/greenpointsfina12.12.D4protectedxls � u,,L CIV OF `'UPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: ( ids & PERMIT # ADD �D 6LAm � rv� L gS6r BUSINESS NAME OWNER'S NAME: S %TA -Y 1. N©izz�) o.f 4,4- PHONE # 4 Org- 7-9 i 2-2-( GENERAL CONTRACTOR: Y -E FAX # 69-3 I am not using any subcontractors: j=am'" Signature Date Please check applicable subcontractors and complete the following information: Owner/ Contractor Signature Date 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