09020023 CITY OF CUPERTINO 7777777!7777:777-77.7
BUILDING DIVISION PERMIT CHIT iAt I�1TI �
BUILDING ADDRESS: PERMIT NO.
10516 N FOOTHILL BLVD B TBD — TO BE DETERMINED
OWNER'S NAME: PERMIT L95UE DATE
PHO SXAMMU 2 e 0 9 CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a O p LICENSED CONTRACTOR'S DECLARATION Job Description
mI hereby affirm that I am licensed under provisions of Chapter 9(commencing
U C Gra with Section 7000)of Division 3 of the Business and Professions Code.and my license is
H in mu force and efty f /' NEW V.'R SVC FRM METR TO HOME (DUPLEX)
j UI2 License Cls-+ 3 ti.+ Lic.8 g Q v q 7
3�t°pi Date la _AACHrfE�s�ECiaR161v 42
A **NEW PIPES INC. PD FOR BUS LIC 2/4/9
a
U I understand my plans shall be used as public records
UJ'W'y Licensed Professional
y 3 OWNER-BUILDER DECLARATION
01 hereby affirm that I am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5•Business and Professions Code:Any city or county
4
000
� which requires a permit to construct,alter,improve,demolish,or mpair any structure
42- prior to its issuance,also requires the applicant for such permit to file a signed statement
=G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
yt-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 2 9 5 0
y 9.. 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 mon:than five hundred dollars($500} 32613067 . 01
0 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
and Professions Code:The Contractors License Law 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.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.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 Contractor's
License Law.
0 I am exempt under Sec B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 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-
.on,as provided for-by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
0 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 are:
Cartier.;rut err-caen Policy No.�e'A 00
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
1 cenify 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
1 hereby affirm that there is a construction lending agency for the performance of
f1, the work for which this permit is issued(Sec.3097,Civ.C.)
W�.Q Lender's Name
Z Gender's Address
U 0 I certify that 1 have read this application and slate that the above information is
L4 .. correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction.and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
p.r liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued fly: Date
SOURCE ONS.
Aire Pim--��— (9' Re-roofs
Sign ure 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 23532(a)? All rooi's shall be inspected prior to any roofing material being installed.
C]Yes _
Will the applicant or future building occupant use equipment or devices which If a roo 7 is installed without first obtaining an inspection,I agree to remove
'mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
strict?
Cl Yes Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hcalth&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
require wy; ass met prier to issuance of certificate of occupancy. Signatu-e of Applicant Date
d� fir '
Ow or authorized agent Date All roof coverings to be Class or better
CITY OF CUPERTINO
REPIPE/SEWEa2/MAIN SERVICE
CUPEkT1NO PERMIT APPLICATION FORM
APN# i? Date:
'5
Building Address:
105-1K civ h,' r G,vd ,
O er's Name: Phone#:
cvt^ N��,S- o P 1-/o�5 y 3�s- ?-3 93
Contractor: Phone#:qb s 2-6cf_ l g6T
itA� , h C. Fax#:
Contact: Phone#: y o ?f '�,0.2
'4� �✓ 1C• S Fax #:
Contractor License#: G7 p 6 04-7
Cupertino Business License#:
Job Description: �(�' ✓ (,vim fi s ,- v,?Q �.e)j- hIC&I rO rnQ
Residential ®/ Commercial ❑
Valuation:
Project Size: Express Standard El Large ET Major El
Green Building: Please complete relevant portion of the Green Building Checklist& attach it to the
application or if applicable, include in plan set & 1:he sheet index.
Green Building Points:
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary s-1wer
1BPREPIPE Commercial re-pipe per fixture P 1CPRP
1 PGASCOM Commercial Ga:; Piping System P
1-4 Outlets
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 01/07/09
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUPCITY
TING FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Grou
1BCBSC Cal Bldg Standards (;ommission B ALL PERMIT
Fee TYPES
/ 1BSEISMICR Seismic Residential
P
1PRSEWER Residential building
P 1RPSS
sewer/sanitary sewer P 1RPRP
1pRREPIPE Residential re-pipe per fixture
Water Service P 1CPWS or
1BPWSVCS 1RPWS
I
1PPRSEWG Private Sewage Dis,)osal System P
1PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
1BPFIXTURE Plumbing Fixture
P
1PGASRES Residential Gas Piping System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
1PPERMITFEE Plumbing Permit Fee Issuance
P
/ Check P
1PLMBLNCK Plumbing Plan
1PLMBINSP Other Plumbing/gas Insp. P
/ 1TRAVDOC
Travel & Documentation Fee B
/
1BUSLIC Business License B
M.Indoor Air Quality and Finishes
I.use l»-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 LowMo VOC Ad isewes 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
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7.Seal all PaWaboard or MDF 4 IAQ/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 p
. 1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring II 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 Resource pts Y--yes 0
6.Install Recycled Content Carpet with Low VOCs Resource pts y=yes 0
Total Points Available: 1401 1301 57
Total Points Project Received: -01 01 0 0
")Z_ y �
G:data/progs/greer buiidngguidelines/remodelers/greenpointsfinal212!04protected.xis
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
rUPE�TINO
Building Department
JOB ADDRESS: 1 osi 6 ✓v, �bo7`��'I/ ��c' PERMIT #Oq 0,;� U U
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: -e. . o s j, _ FAX#
I am not using any subcontractors: /- '�` �— y--q�—
Signature Date
Please check applicable subcontractors and co m lete 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
e(-) a---- _ 9---
Owner/Contractor
---Owner/Contractor Signature Date