09020081 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � R�� Z� kI�ll
BUILDING ADDRESS: PERMIT NO.
11238 BUBB RD KITCHEN WORKS INC/DBA
OWNER'S NAME. H OMEWOR,� PERMIT LSSUE DATE
TONE: A CONTROL NO.
(415) 45,-)-4696
ARCHITEC IENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u O p LICENSED CONTRACTOR'S DECLARATION
Z'
I hereby affirm That I am licensed under provisions of Chapter 9(commencing Job Description
Z with Section 7000)oC Di Sion 3 of the Business and Professions Code,and my license is
y in full force andeffecL �.-C-4 Qp L RPLC 2 IVNDWS IN KTCHEN NON-STRUCTRL
"'A
'? License ads Lic.tY
=� Date„ /i F OSI Contractor
ARCHITECTS DECLAR ON
I understand my plans shall be used as public records
DyU
4 Q y Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
C p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
n fgL 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 Lri:ense Caw(Chapter 9 Sq.Ft.Floor Area Valuation
Y.tz- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $6900
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(M). 3620603.3 . 00
[11.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 Contractor's License Caw 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 Li-
cense Caw 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.
❑I am exempt under See. 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 Conscnt to self-insure for Worker's Compen-
.,adon,as provided for by Section 3700 of the Labor Code•for the performance of the
work for which this permit is issued.
RI 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��'L r's Compensation Insurance carrier and Policy number arc:
CartierY 1 ter)J Policy No.:71,3—6,0/0;7,/e-
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,I 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.
Z " CONSTRUCTION LENDING AGENCY
(~—t rte. I hereby affirm that there is a construction lending agency for the performance of
p!> the work for which this permit is issued(Sec.3097,Civ.C.)
W�A Lender's Name
L
Z
ander's Address
U 0 1 certify that 1 have read this application and state that the above information is
LL corccL I agree to comply with all city and county ordinances and state laws relating to
0V building construction,and hereby authorise representatives of this city to enter upon the
U above-mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
rA liabilities,judgmcnts,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit y Date -�
t"r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: "
SOUR GULATIONS. �/�1n5
Re-roofs _
Signature of Applicant/Contractor 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 M532(a)7 All roofs E hall be inspected prior to any roofing material being installed.
C]Yes �llo
Will the applicant or future building occupant use equipment or devices which If a roof iE installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Ycs �,No
I 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 c ndy have a tenant that it is my responsibility to notify the occupant of the
requi which must be e° to issuance era certificate of Ocea cy. Signature of Applicant Date
�� All roof coverings to be Class W'or better
Owner or authorized agent Date
tat
CITY OF C.UPERTINO
CITY OF
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # 2 / D U U D Date: azf�
Building Address:
11;2-S5-
bo�b,i
r
a
Mailing Address (if different
from building address):
Owner's Name: 41/n r a 1/ /I Phone#:
HOA: (Exterior work only) Yes L No (�]
If yes, provide letter from HOA
Contractor: % T in Wad ' Phone:ck/1'0
Fax: JJ
Contractor License#: -oma ,S 6
Cupertino Business License#:
Contact:�t Phone• (, /0—
Fax:
Residential Commercial
Job Description: �y
/V"
Building Permit Info:
Bldg Elect ❑ 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: 61 S n d Square Footage:
Project Size: Express M _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.builditgreen.or
Revised 02/05/09
CITY OF C.UPERTINO
CUCITY
OF O GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1 GENCOM
1 STUCOAP Stucco Applications (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea :3 windows)
1 WINMEWSTR New Window-structural shear B
wall/masc my(includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
I 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 flan Check (when no E/M/P) B
when not over counter) hourly-stand alone
/ 1 BCBSC Cal Bldg standards Commission Fee B ALL PERMIT
TYPES
IBSEISMICR Seismic Residential B
IBSEISMICO Seismic Commercial B
1 TRAVDOC Travel & :Documentation B
1BUSLIC Business License B
` of 5
INPUT Resources Energy ,D
M.Indoor Air Quality and Finishes
1.Use Low/No-VOC Paint 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes i 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 31AQ/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
N.Flooring
1.Select FSC Certified Wood Flooring E 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 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
Total Points Available: 1 40 130 57
Total Points Project Received:
G:data/progslgreer buildingguidelineslremodelers/greenpointsfina12.12.D4protectedxls
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