09020050 CITY OF CUPERTINO
BUILDING DIVISION PERMIT 1�� � � � •
BUILDING ADDRESS: PERMIT NO.
10455 HENEY CREPE PT, RMI MF.
OWNER'S NAME: PERMIT ISSUE DATE
I S A 2"9CONTROL NO.
650) 583-6200
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u O p LICENSED CONTRACTOR'S DECLARATION Job Description
urI hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z ha with Section 7000)of Division 3 of the Business and Professions Coo}rIA my license is
yin full force and effect. 7vl RE PLC FURNACE
z L' 'm C Lic.M
y Z 14
0 Date Contractor
ARC ITECTS DECLARATION
1 understand my plans shall be used as public records
ryU
.cin Licensed Professional
rn OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
e m Pi which requires a permit to construct,alter,improve,demolish,or repair any structure
'r z prior to its issuance,also requires the applicant for such permit to file a signed statement
E_e that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
F$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 2
y�9 that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(M). 3 4 2 4 8 C�16 . 00
❑I,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 dors not apply to an owner of q P
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 Contractors Li-
cense Law docs not apply to an owner of property who builds or improves thereon,and•
who contracts for such projects with a cont actors)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Seo. B&P C for this reason
Owner Date
WORKER'S COMPENSA71ON 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 Workers Compen-
_.non,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 Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Wor es Compensation Insurance carrier and Policy number am: q
Cartier. Policy o.-000959 ln `O
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or Icss.)
I certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of Califomia.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.
CONSTRUCTION LENDING AGENCY
Fr rte+ I hereby affirm that there is a construction lending agency for the performance of
(1! the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
Z Lenders Address
U 0 1 certify that I have read this application and state that the above information is
(Sr r" correct 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
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
E.,to liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z hn quencc of the ranting of this permit Date ' ' S
►-t APL NT UNDE S SAND WILL COMPLY WITH ALL NON-POINT Issued by:
SO EGU T1
2 Re-rooi's !' _
Sign m of pp• t/Contrac r te
AZARDO ALS DISCLOSURE Type of Roof
Will ap cantor future building occupant store or handle hazardous material
as de ed by Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Sc n 25532(x)? All roo's shall be inspected prior to any roofing material being installed.
❑Yes Q.l4o
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
;t hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
strict? �
❑Yes QNu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
ni Ilh&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
'currently have4 that it is my responsibility to notify the occupant of the
req're cots which m t m' rior to issuance of a Ccrtific n
n Ocahp I- Signature of Applicant Date
O ncr or t ri d agent LALC
All roof coverings to be Class'R'or better
o
CITY OF CUPERTINO
' FL;RNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN # L 0 Dater
Building Address:
r b 5
Owner's Name: Phone#: ���
C, M s�
Contractor: Phone #:6p low.07V
eAA / Meel-hanlG�l Fax#: use
Contractor License #: Cupertino Business License #:
31) 4
Contact: Phone#: e? --SS3--6e2..&0
M K L°�l/ T Fax #:
Building Permit Info:
Elect Plumb ❑� Mech
Residential Commercial ❑
Job Description:
p l �c if Fvt,v ;�Ac e
For Residential Installations:
Attic ❑ 1"floor. 2nd floor ❑
Adhere to minimum setback requirement ❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installa:ion El
installation PlanningApproval Required []
Cost of Project: Type of Construction (Usage Class):
I-tq"-), �g-
Strapped On Platform ❑ Bended ❑ New Location ❑ Replacement
Project Size: Express ❑ Standard ❑ LarJe ❑ Major ❑
Valuation:
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. C7�—.
' Revised 01/07/09
CITY OF CUPERTINO
FURNACE/AC
"UPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Descripti an Fee Permit Type
Group
FURNACE FURN/AC
1 MCRAA Commercial-R(:pair/Alteration/Add to M
ea heating appl ance,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,absorption or
evaporative cooling system,incl
installation of controls regulated by this
code.
1 MCREPALT Commercial for the repair of alt/add to M
ea heating appli ance,refrigeration
unit,cooling unit,VAV boxes,
absorption unit or ea heathing, cooling
absorption,or e-aporative cooling sys,
incl install of controls regulated by
this code.
1 MCSUSHTR Commercial Install/Relocate ea M
suspended heati;r,recessed wall htr, or
floor mounted unit heater.
1PGASCOM Commerical foi ea gas piping System P
1-4 outlets
1 BPGAS For each gas piping system of 5 or P
more per outlet.
1 MCAPPVNT Commercial for the install/relocate/ or M
replacement of-.a appliance vent
installed & not incl in an appliance
permit.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Commercial Seismic B
1 MRRAA Residential Rer air/Alteration/Add to M
ea heating appliance,refrigeration unit,
cooling unit,ab;orption unit,or ea
heating,cooling,absorption or _
evaporative coc ling system,incl
installation of cz)ntrols regulated by
this code.
1MRSUSHTR Residential Install/Relocate ea M
suspended heatt;r,recessed wall htr, or
floor mounted unit heater.
CITY OF C.-UPERTINO
FU"'ACE/AC
CUPCITY
TING FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Grou
I MRAPPVNT Residential for the install/relocate/ or M
replacement of ea appliance vent
install ¬ incl in an appl permit.
FURNACE
FURN/AC
1 PGASRES Residential for ea gas piping system of P
1-4 Outlets
1BPGAS For each gas piping system of 5 or P
more per outlet.
IBCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
` TYPES
1 IBSEISMICR Residential Seismic B
I MECPLNCK Mechanical P.an Check M
1MFR=<100 Furnace Syst <=100k BTU install or M
relocate ea forced-air/gravity type
furnace/bumcr, incl ducts/vents
attached to si.ch appliance up to and
include 100,00 Btu/h
IMFRN>100 Furnace Syst> 100k BTU install or M
relocate ea forced-air/gravity type
furnace/burn,,-r, incl ducts/vents
attached to such appliance over
100,000 Btu/h
I EPERMITFEE Electric Permit Fee E
IMPERMITFEE Mechanical -?ermit Fee M
1PPERMITFEE Plumbing Permit
P
ITRAVDOC Travel Documentation B
r B
1BUSLIC Business Li:,ense
M.Indoor Air Quality and Finishes
1.Use LAW'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 Los%VOCAdha*a 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
0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes
7.Seal SII F�cpo>�edPareboardo{UN 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 0
N.Flooring
1.Select FSC Certified Wood Flooring 8 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
Total Points Available: 1 1401 1301 57
Total Points Project Received: 01 0 01
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Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
-UPEkTINO
Building Department
JOB ADDRES : PERMIT # �� Q� 0
In (Dq
OWNER'S NAME: C ) PHONE
GENERAL CONTRA R: FAX #
I am not using any subcontractors:
2 0
tore Date
Please check applicable subcontractor d Com9 followin 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