09020103 CITY OF CUPERTINO � Z � �N'
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS: AL AR 1
PERMIT ISSUE DATE
10445 RYRNE
OWNER'S NAME: CONTROL NO,
PHO 209) 8.23-2525
BUILDING PERMIT INFO
B� E� PLUMB M
ECH
ARCHITECT/ENGINEER:
Job Description
I O p LICENSED CONTRACTOR'S DECLARATION p EL:
m I hereby affirm that I am lice u under provisions of Chapter 9(commencing REPLC E .TNG METER SOCKET W/NEW MN
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is
n<W. in full force and cft
;�z License Cl - comraetnr �.,,��a E +ire . W/DISCorfNCT**BUS LIC RENEWD 2/25/
9 ZALUNARDO
+F Lu Date ARCHITECT'S DECLARATION ELECT
1 understand my plans shall be used az public records
5 0
u.F- Licensed Professional
p OWNER-BUILDER DECLARATION
n r I hereby affirm that 1 am exempt from the Contractor's License Law for the
City Of county
n O following reason•(Section 7(131.5,Business and° adc�mt lith or repair any Structure Valuation
which requires a permit to construct alter.imp :Sq.Ft.Floor Area
4 w prior to its issuance,also requires the applicant for such permit to file s signed statement
Z< 00
that he is licensed pursuant to the provisions of the Contractor's License[ave(Chapter 9
Y (commencing with Section 7000)of Division 3 of the Business and on.Any
professions
aeon of Occupancy Type
i that he is exempt therefrom and the basis for the alleged exemption Any ApN Number
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 35712036 . 0 0
not more than five hundred dollars($500)•
O I az owner of the property,or my employees with wages as their solo compensation, Required Inspections
will do the work and the structure is not intended or offered for sale(Sec,7044.not aPPIY to in Business
and Professions Code:The Creon,and who does stLaw�ich work himself or through his
Property who builds or improves
own employees,provided that such improvements are not intended or offered for sola I,
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.).
O 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-
reon,and.
cense Law does not apply W an owner of property who builds or improves rsuam the Co tors
who contracts for such projects with a contractor(s)licensed p
License Law. B&P C for this reason
1 am exempt under Sea
Date�—
Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 hive and will maintain a Certificate of Consent to self-insure for Worr ess Coomop enn'
.ion,as provided for by Section 3700 of the Labor Code,for the Performance
f the
work for which this permit is issued• uircd b Section
1 have and will maintain Workefs Compensation Insurance.as req Y
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 n.7 umber,am'
Cartier.f_ ' 6,!„i]) policy?0.: vim.;—
CERTIFICATE OF PTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is Cor 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 this Certificate of Exemption,you should
NOTICE TO APPLICANT:If,after making
become subject to the Worker's Compensation provisions of the Labor Code,you must
Z
forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY Ix
din for the performance of
vN. I hereby affirm that there is a construction lenagency
> the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Namc
0. Lender's Address
[certify that 1 have read this application and state that the above information is
V co rccL I agree to comply with all city and county ordinances and state laws relating to
0 H building construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes
harmless the City of Cupertino against
,7+a (We)agree to save,tnd expert and keep Date —
H liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z inconsequence of the granting of this permit.
-+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUR u ,n Re-rc ofs
nUconifacLor °"� 'Type of Roof
HAZARDOUS
Signature ApQlica
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material being installed.
aterial
az defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety All roofs shall be inspected prior to any roofing m
Code,Section 25532(a)? �Na
If a roof is installed without first obtaining an inspection,I agree to remove
❑Yes
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 all nt;w materials for inspection.
trict?
❑Yes °
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
niaHealth&Safety Code,Sections 25505,25533 and n34i 1 understand to of occupant
ndrt Date
y the
dons not currently have a ant that
or issuanceof a Ccruficate of Occupancy. Signature of Applicant
requirements —� All roof coverings to be Class'A"or better
Date
Owner or autho'.d agent
of 6 3
CITY OF 1XPERTINO
CUPEI�TINO GENERAI� BUILDING
PERMIT APPLICATION FORM
APN # 3:5 ( 'l - '3 Date:
Building Address:
10,/415 Byrne Cvertiho C4
Mailing Address (if different from building address):
Owner's Name: No A Phone#:
far i� ck Cdrl t
Contractor: Phone: 'Q 4- a23 -aS 25-
Fax:
SFax:
Contractor License#: j�ygogj_
Cupertino Business License#: 302
Contact:
Phone: cj. CDB-yq I
�J�r�s Zglv�awdo Fax:
Residential Commercial
Job Description:
Rt131o�ce XiS'h�h9 Mcivr Sock t with h ew Moll h p,1nt
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,`'-B 0
Valuation: Square Footage:
Project Size: Express 53jjA§<andard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applica':)le, include in plan set& the sheet index.
Points Achieved:,
For help, contact Build it Green at www.buildWareen.or
Revised 01/07/09
a - CITY OF CUPERTINO
CITY Of GENERAL BUILDING APPLICATION
CUPEkTINO FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sfl B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1WINMEWSTR New Window-structural shear B
wall/masDnry(includes plan ck fee)
IEPERMITFEE Electrical Permit Fee E
1 MPERMI -FEE Mecham Sal Permit Fee M
1PPERMITFEE Plumbin;Permit Fee P
IELCPLNCK Stand Aone Electric Pln Ck (hourly) E
1 MECPLNCK Stand Aone 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-:tand alone
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel k Documentation B
1BUSLIC Busine;;s License B
5 of 5
M.Indoor Air Quality and Finishes
1.Use L,vwlt+lo-VOC Palm 1 IAQ/Health pts y=yes 0
2,Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3.Use LDwMb VOC 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--yes0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7.Seal all Eq= dlP,atOObOaMl V WF 41AQ/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
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes I 1 0
1 1 1
N.Flooring
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 1401 130r- 57
Total Points Project Received: 01 0 0
G:data/progs/gn tenbuilcingguidelines/remodelers/greenpointsfinal2.12.04protected.As
Community Development
.4 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
CITY OF
-47UPERTINO
Buildi�n De ar"I
JOB ADDRESS: PERMIT # n O `
1GygS l3yrnc CUpe�'}iho G4
OWNER'S NAME: Ckvck C-arl PHONE # Q L
GENERAL CONTRACTOR:Z q/Vi Vj0 Cz ;c c. FAX#
I am not using any subcontractors: Date
Si;;nature
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