09020024 CITY OF CUPERTINO
BUILDING DIVISION
PERMIT +G�I4►£ � N } TIQ�N�
BUILDING ADDRESS: PERMIT NO.
10241 JOHNSON AVE JAMES BULL
OWNER'S NAME: PERMIT ISSUE DATE
j@14NSGN AVE
pulp SQR A CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a O p LICENSED CONTRACTOR'S DECLARATION Job Description
tat C I hereby affirm that I am licensed under provisions of Chapter 9(commencing
n<a with Section 7000)of Division 3 of due Business and Professions Code.and my license is
in full force and effect. REPAIF SEWR LINE
Z License Class Lic.lt
'- DateContractor
EFg ARCHITECTS DECLARATION
eC< I understand my plans shall be used as public records
D U
Licensed Professional
n 3 OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
COO following reason.(Section 7031.5•Business and Professions Cale:Any city or county
which requires a permit to construct,alter•improve,demolish•or repair any structure
y Z y prior to its issuance,also requires the applicant for such permit to file a signed statement
F=o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
yF$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of $350
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(5500).
❑1,as owner of the property,or my employees with wages as their sole compensation, 3 3 7 51 E 0 2 7 . 0 0
will do the work•and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Cede:The Contractor's 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.). �,..
❑I•as owner of the property,am exclusively contracting with licensed contractors to ov
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li. *-
cense Law docs not apply to an owner of property who builds or improves thereon,and. TAx
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License
❑1 exempt u er Sec B P C for this reason
Owner Dt 7
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
-ion,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 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 Workees Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need trot be completed it the permit is for rine hundred dollars($100)
or less.)
I certify that in the ce of the work for which this permit is issued,1 shall not
employ any I to any ncr so as to bcco c ect to the Workers'Compensation
Laws of Cali mia Date
Applicant
NOTICE TOA CAM:If,after making this Certificate of Exemption,you should
become subjc to the Worker's Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z 0.4 CONSTRUCTION LENDING AGENCY
[� I hereby affirm that there is a construction lending agency for the performance of
Ix the work for which this permit is issued(Sec.3097,Civ.C.)
WW Q Lender's Name
Z
Lender's Address
U C) I certify that I have read this application and stale that the above information is
[L" correct I agree to comply with all city and county ordinances and state laws relating to
O 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
liabilities,judgments,costs and expenses which may in any way scenic against said City
U Z in consequence of c granting of this permit
�+ APPLICA N ERSTANDS AND W1)&-CO LY WITH ALL NON-POINT Issued f y: Date
SOURCE U NS.
2 e-roof;
Signature pplicanut-ontractor Date r �;
IV 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 25532(a)? �, All roots shall be inspected prior to any roofing material being installed.
❑Yu
Will the applicant or future building occupant use equipment or devices which If a room is installed without first obtaining an inspection,I agree to remove
t hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
rict?
❑Yes
I have read the hazardous materials requirements under Chaptcr 6.95 of the Califor-
nia afety Code,Sections 25505,25533 and 25534.1 understand that if the building
d not c oily have a tenant, is my responsibility to notify the occupant of the
quire ts which must be met to issuance of Certificate of Occupancy. Signat)A of Applicant Date
nor orant/h n cd agent o„evey� All roof coverings to be Class" "or better
CITY OF CUPERTINO
,aZ
REPIPE/SEWER/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN# �-7 , �,� Date:Z q
Building Address: [�
Owner's Name: Phone#:
Contractor: Phone#:
Fax#:
Contact: Phone#:
Fax #:
Contractor License#:
-
Cu ertino Business icense#:
Job Description:
Residential Commercial ❑
Valuation:
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 Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
1BPREPIPE Commercial re-pipe per fixture P 1CPRP
1 PGASCOM Commercial Cias Piping System P _
1-4 Outlets
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
IBSEISMICOM Seismic Commercial P
Revised 01/07/09
CITY OF CUPERTINO
REPIPE/SEWEIVMAIN SERVICE
CUPEf�TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1BCBSC Cal Bldg Sta.ndaris Commission B ALL PERMIT
Fee TYPES
/ 1BSEISMICR Seismic Residential P
1PRSEWER Residential build.ng P 1RPSS
sewer/sanitary sewer
1PRREPIPE Residential re-pipe per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1 PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
1 BPFIXTURE 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
1PLMBLNCK Plumbing Plan Check P
1PLMBINSP Other Plumbing/,;as Insp. P
r 1TRAVDOC Travel &Documentation Fee B
( 1BUSLIC Business License B
.Indoor Air QualitY an m►ses 0
1.Use�-VOC Paint es 1A(yHealth pts y=yes 0
21AQ/Health pts y=yeS
0
2.Use Low VOC,Water-Based Wood Finishes IAQ/Health pts y=yes
3.Use LOW)M VOC Adhesives Resource pts y=yes 0
4.Use Salvaged Materials for Interior Finishes
5.Use Engineered Sheet Goods with no added Urea 0
(i IAQ/Health pts y=yeS 0
Formaldehyde I IAQ/Health pts Mes
6.Use Exterior Grade Plywood for Interior Uses 0
7.Seal all Pad ddmd or MDF IAQ/Healthpts y=Yes
4 Resource pts y=yeS 0
B.Use FSC Certified Materials for Interior Finish 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=YeS 0
p ,
10.Install Whole House Vacuum System 3 IAQfHealth ts y=yes. ( �
N.Flooring 0
3 Resource pts y=yes
1.Select FSC Certified Wood Flooring 4 Resource pts y=yes 0
2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=Yes 0
3.Use Recycled Content Ceramic Tiles 0
5 IAQ/Health pts Y=yeS 0
4.Install Natural Linoleum in Place of Vinyl 4 Resource pts y=yes
5.Use Exposed Concrete as Finished Floor p
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes ' ` 1
tal Points Available: :14310 130 57
To 0
Total Points Pro'ec=Received'
0 0
C
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• OWNER-BUILD17R VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform:
A. _/_�the work authorized by this permit
B. _ A portion of the work
C. _ None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. A portion of the work (complete section below)
Contractor Address/City, Phone # State License # Type of work to
3. _ I will utilize unlicensed persons; other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
PersorVFirm Address/City . Phone Number Type of work to be
performed
..........................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information(rev a side). p�
Property Owner'slSignature: Date:
-Lu=g
Job Address: / � `—� Permit#
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
CITY OF
-'UPEkTINO
Buildin De artment
JOB ADDRESS: PERMIT # �0
OWNER'S NAME:
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: Date
Signature
Please check applicable subcontractors and corn .ete the folio' �Borma on: S LICENSE #
ti
SUBCONTRACTOR BUSINESS NAM
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 Nkktal
Sheet Rock
Tile ,
—J)Z
Owner/ ontractor Signature
Date