09020087 CITY OF CUPERTINO C1TRAli"T ? � TI �1.'
BUILDING DIVISION PERMIT pEItMITNO.
BUILDING ADDRESS:
1 EY pERIviIT ISSUE DATE
OWNER'S NAME:
A CONTROL NO.
^rr0
408) 294 BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB
MECH
'3 O p LICENSED CONTRACTOR'S DECLARATION Job Description
VI hereby affirm that I am licensed under provisions of Chapter 9(commencing
z U with Section 7000)of Division 3 of the Business and Cessions Codc'and my case is RE PLC FU RNAC E
Ow in full fora and effect Lie k !/
W3 L(eenso CI `
n F p Dam Con
ARCHITECTS DECLARA ON
15 tt I understand my plans shall be used as public records
1
c c y Licensed Professional
OWNER-BUILDER DECLARATION
I hereby alTirm that I am exempt from ft Contractors License Law for the
no [allowing reason.(Section 7031.5,Business and profcWons Code:Any city or county
K m Pi which requires a permit to construct,alter.imP--demolish,or repair any structure Valuation
4—m Prior to its issuance,also requires the applicant for such permit to file a signed statement t' Ft.Floor Area
that he is licensed pursuant to the provisions o(thc Contractor's Liccnsc Law(Chapter 9 `�q'
F$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y .. that he is exempt therefrom and the basis!ar tite alleged exemption.Any violation o[ APN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars(5500)• 35616029 . 00
O 1,as owner of the property.or my employees with wages as their sole compensation, Required Inspections
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
awn 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 Contractor's Li-
cense Law does not apply to an owner of property who builds or improves themon,and
who contracts for such projects with a cont actors)licensed pursuant to the Contractor's
License Law. B&P C for this reason
I am exempt under Sec
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 Consent to self-insure for Worker's Compen-
Aon,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
1 have and will maintain Workees Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worked ompensation In ursnce carrier and Policy no
��
Cartier.
Policy No.:
ATE O EXF-MPTION FROM WORK S'
COMPENSATION INSURANCE
(Phis section need not be completed if the permit is for one hundred dollars(S 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
`,Z, forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
HrA I hereby affirm that there is a construction lending agency for the performance of
IYi> the work for which this permit is issued(Sec.3097,Civ.C.)
W A
Lender's Name
f]t Lender's Address
1 certify that 1 have read this application and state that the above information is
V. 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
W above-mentioned property for inspection purposes
LL (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City Date
U Z in consequence of the granting of this permit
-+ APPLICANT UNDERSTAN S NO
W COMPLY WITH ALL NON-POINT Issued b y:
SOURCE REG —
Re-roof:
Signature ppl' antra r Dam Type of Roof
AZAR OUS MATERIALS DISCLOSURE YP
ill applicant or future building occupant store or handle hazardous material
as ittned by the Cupertino Municipal Code.Chapter 9.12,and lite Health and Safety
Code.Section 25532(a)? All roof 3 shall be inspected prior to any roofing material being installed.
C3 Yes No If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or fut building occupant use equipment or dcviccs which all new materials for inspection.
it hazardous air conuminan cfincd by the Bay Arca Air Quality Management
'trict?
0Yes ❑No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
Llth&Safcty Code.Sections 25505,25533 and 25534.1 undcrstand that i!the buildingt currently have a ten a is m nsibility to notify lite occupant of theSlgnatU"e Of ApplicantDate
ments which m m cc of crtif f OccupancyAll roof coverings to be Class"} or better
or authorize gent
Dam
00$
CITY OF CUPERTINO
a FUWiACE/AC
CITY OF _ - -
CUPEk INO PERMIT APPJ JICATION FORM
APN#25� � � 09. Ov Date:
BJJuil//ding Address:
Owner's Name: Phone#:
er8
Cont ctor: Phone#: Lf 00 ( �a
Olt D , � Fax #: Lf0$
Contractor Li ense#: Cupertino Business License#:
ontact:
Phone
� h* #off er (•tea
Tom, L Fax#:
Building Permit Info:
Elect B— Plumb (l' Mech
Residential Commercial ❑.
Job Description:
For Residential Installations:
Attic Ellst floor 2"a floor ❑
Adhere to minimum setback requirement []
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installatio a ❑
New installation Planning Approval Re uired ❑
Cost of Project: Type of Construction(Usage Class):
lot �� -q
Strapped ❑ On Platform ❑ Bonded ❑ New Location ❑ Replacement
Valuation:
Green Building: Must attach Green Building C heck list to this application
date:_ Build It Greed
Single Family GireenPo�int Checklist 5mariSolutionsFrom MeGround Up
The GreenPoint Checklist is based on the various green features incorporated into the home and 1;the
basis for the GreanPoint Rated program.A home can be considered green if if fulfills the prerequis ites,
9
cams at least 50 points,and meats the minimum points per category:
Energy(30),Indoor Air Qua ity _
Health(5);Resources(6),and Water(9).Please contact Build It Green for a list of qualffied Greer Point
Raters it you are interested in pursuing third-party varification.New Home Construction Green Bui ding — — —'
The grean building practice=_listed below are described in th_
Guidelines,available at wym,builditareen.om.
T V
T11 .
ENTEsssOJECT l - w a
Points Available Par Measure
A.SITE
1.Protect Topsoil end Minimize Disruption of Existing Plants&Trees
❑ a.Protect Topsoil from Erosion and Reuse after Construction _ — 0
ELM andDalinsate Construction F oo_Wnnt fol M�rmum Pf CtrDn I 0 I 3
❑ 2.Deconstruct instead of Demolishing Usting Buildings On Site
3.Recycle Job Site Construction Waste(Including Green Waste) 0 R _
❑ a.Nfrnimrum 5o%Waste Diversion by Weight(Recycling Or Reuse)•Required 0 — 2
❑ b.Minimum 65%Diversion by Weight(Rey cling or Reuse) 0 2
C] c.Minimum BD%Diversion by Weight(Recycling or Reuse)
4.Use Recycled Content Aggregate(Minimum 25°m) 0 1
❑ a.Walkway and Driveway 0 1
❑ b.Roadway Base To al Points Available in Site=12 0
Points Available Per Measure
3b.AIINewPI9R
ION --
ace Portland Cement in Concrete with Recycled Flyzsh or Slag 0 — 1
—— nmum 20°.-FI s or Slaginimum 25%Flyash or Slag 0 ' 3
Frost-Protected Shallow Foundation in Cold Areas(C.E.C.Climate Zone 16)Radon Resistant Construction(in At-Risk Locations Only)ign and Build Structural Pest Controls nstall Termite Shields&Separate All Exterior Wood-to-Concrete Connections by Meta or Plastic FastenerslDividz s 0
il New Plants Have Trunk,Bese,or Stem Located Ht Least 36 Inches from Foundatiior Total Points Available in Foundation=8 0
Points Available_Per Measure
C.LANDSCAPING
1.Construct Resource-Efficient Landscapes p _ 1--
❑ a.No Invasive Species Listed by Cal-IPC Are Planted
❑ b.No Plant Species Will Require Hedging 3
❑ c.75%of Plants Are Drought-tolerant California Natives,Medtemanean,or Other Appropriate Species 1 0 i 1
❑
2 Use Fre-Safe Landscaping Techniques
3.Minimize Turf Areas in Landscape Installed by Builder p I 2
❑ a.All Turf Will Have a Water Requirement Less than or Equal to Tall Fescue(50.6 plant actor) D — i
❑ b.Turf Shall Not Be Installed on Slopes Exceeding 10%or in Areas Less than 8 Feet Wi ie 0 — — _; 2
❑ c.Turf is Sia%of Landscaped Area(total 2 points) 0 2
❑ d.Turf is 5510%of Landscaped Area(total 4 points) 0 3
❑ 4.Plant Shade Trees 0 2
❑ 5.Group Plants by Water Needs(Hydrozoning)
6.install High-Efficiency Irrigation Systems 0 2
❑ a System Uses Only Low-Flow Drip,Bubblers,or Low-flow Sprinklers 0 3
EF� 7.
Has Smart Controllers 0ate Two Inches of Compost in the Top 6 to 12 Inches of Soil
o2
l Planting Beds to the Greater of 2 Inches or Local Water Ordinance Regr ilemeSalvaged or Recycled-Content Materials for 50%of Non-Plant LandscapElements Light Pollution by Shielding Fxtures andlor Directing Light Downward Totes Points Available in Landscaping=311 D
PDinia nvallable Per M.Bas�ire
B.STP.UCTUPAL FRAAM&BUILDING EN`V LOPE
1.Apply Optimal Value Engineering 0 1 —
❑ a.Place Rafters and Studs at 24-Inch On Center Framing 0 1
❑ b.Size Door and Window Headers for Load 0 1
❑ c.Use Only Jack and Cripple Studs Required for Load
2.Use Engineered Lumber 0
❑ a.Beams and Headers 0
❑ b.Insulated Engineered Headers 0 — 1 -
❑ C.Wood 1-Joists or Web Trusses for Floors —0 ---
❑ d.Wood I-Joists for Roof Rafters 0 -- 1 --—
❑ e.Engineered or Finger-Jointed Studs for Vertical Applications p
❑ f.Oriented Strand Board for Subfloor 0 1
❑ g.Oriented Strand Board for Wall and Root Sheathing
3.Use FSC-Certified Wood 0 __ 2 ----
❑ a.Dimensional Lumber,Studs and Timber.Minimum 4D%
❑ b.Dimensional Lumber,Studs and Timber:Idinimum 70%
❑ c.Panel Products:Minimum 40% D_ 1
❑ d.Panel Products:Minimum 70916
Pape 1 of 4
@2007 Build It Green
Sinole Fami v GreenPoint Checklist 2007 Version
Community Development
10300 Torre Avenue
4k„
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
CITY OF
';UPERTINO t
Buildir� De artmen
PERMIT #
JOB ADDRESS: ate- }d1:5,o
�"�
LF
rX#
E # — D
OWNER'S NAME: w
GENERAL CONTRACTOR: � z`c`
I am not using any subcontractors: Signature Date
Please check applicable subcontrac rs and complete the following information:
LICENSE #
SUBCONTRACTO BUSINESS NAME
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
Date
Owner/ ontractor Signature