09070083 CITY OF CUPERTINO C1' TIi+ {?R Z (? TEIt'
BUILDING DIVISI01',1 PERMIT
PERMIT NO.
BUILDING ADDRESS:
21065 LA RET PERFO EV1RPERMrr ISSUE DATE
OWNER'S NAME:
A CONTROL NO.
7N
4 0 8) 9 2 0-617 0 BUILDING PERMIT INFO
ARCHI7ECT/ENGiNEER: BLDG ELECT PLUMB MECH
a o 0 0
Z c c LICENSED CONTRACT'OR'S DECLARATIDN Job Description
UI hereby affirm that I am licensed under provisions of Chapter 9(commencing
z with Section 7000)of Division 3 of the Business and Professions Code.and my license is RE PLC FL RNAC E & ADD A/C
n<o. in full force and effect. G ` '?�
D gi z License Class G�� Lie.X
Date '2—�c.-tom—Contractor
ul ARCHIrECrS DEC RA ON
a` I understand my plans shall be used as public records
Du",
a y Licensed Professional
OWNER-BUILDER DECLARATION
y I hereby affirm that 1 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
which requires a permit to construct.alter,improve,demolish,or repair any structure Valuation
4-w prior to its issuance,also requires the applicant for such permit to file a signed statement S Ft.Floor Area
::z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 • q
z t=-S (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
00
a that he is exempt therefrom and the basis for
the alleged exemption Any violation of APN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more man five hundred dollars(M). 3265500" . 00
❑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
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,me owner-
builder,will have the burden of proving that he did not Wild or improve for purpose of
sale.).
O I,as owner of the property.am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Convutor's Li-
cense Law does not apply to an owner of property who Wilds or improves thereon,and
who contracts for such projects witha contractor(s)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 or Consent to self-insure ror Worker's Compen-
-don,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which his permit is issued.
❑I have and will maintain Worker's Compensation Insurance,az 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 Policyy number are:
Carrier.
•"moi:r�:2Yx-'fY1at'�s'"PoticyNNo.'.- /46Ci I f) 2-�Z 3
CERTIFICATE
OF XEMP INSURANCE
WORKERS'
(This section need not be completed if the permit is for 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 az to become subject to the Workers'Compensation
Laws of California.Dam
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
F~•c ter I hereby affirm that there is a convection lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
az Lender's Address
V I certify that I have read this application and state that the above information is
V.H correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building convection,and hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes.
>4 OWa (We)agree to save,indemnify and keep harmless the City of Cupertino against
rA liabilities,judgments,costs and expenses which may in any way accrue against said City Date 2 I n
U Z in consequence of the granting of this permit.
►� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: /
SOURCE I�GULATIONS.
f /i �' 2- - " Re-roofs
Sigitatdre lirant/ ontractor
? Date T of Roof
HAZARDOUS MATERIALS DISCLOSURE Y
Will the applicant or future building occupant store or handle hazardous material
az defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? Jr" / All roofs shall be inspected prior to any roofing material being installed.
C3 Yes ° If a root is installed without first obtaining an inspection,I agree to remove
Will the applicant or future Wilding occupant use equipment or devices which all new materials for inspection.
it hazardous air contaminants az do cd by the Bay Area Air Quality Ma -
nes mcnt
strict?
0Yes N°
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
niaHealth&Safety Code,Sections 25505,25533 and 25534.1 understand that if the Wilding
does not currently have a tenant.that it is my responsibility to notify the occupant of the Date
reyuiremc ts�whicht W m t r to issu c of a Certificate of Occupancy. Signatue of Applicant
All roof coverings to be Class r',�."or better
O r o ent
Date
oqa
CITY OF CUPERTINO
FURNACE/AC
CUPS
%C-Ior
PERMIT APPLICATION FORM
APN # Date: _
Building Address:
Owner's Name: Phone#:
b'Z
- r� ,�/&,<^ 57— cl;W) V
Contractor: Phone#:
--� Fax#:
Cupertino Business License#:
Contractor License#:
Contact:
Phone#: c4c, C, -_L / 7G
�J �F /?,�.�i�TZ(t"moi �✓ Fax#: Z C 7
Building Permit Info:
Elect[ Plumb Mech [�
Residential Commercial E]
Job Description:
For Residential Installations:
1St floor [� 2nd floor ElAttic
Adhere to minimum setback requirement [�
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) El
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction (Usage Class):
1 �
Strapped ❑ On Platform Bonded New Location Replacement
Project Size: Express ❑ Standard Large❑ 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.
Revised 01/07/09
CITY OF C.UPERTINO
FURNACE/AC
CUPEI�TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
FURNACE FURN/AC
1MCRAA Commercial-Repair/Alteration/Add to M
ea heating appliance,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,absorption or
evaporative cooling system,incl
installation of omtrols regulated by this
code.
1 MCREPALT Commercial for the repair of alt/add to M
ea heating appliance,refrigeration
unit,cooling unit,VAV boxes,
absorption unit or ea heathing, cooling
absorption,or evaporative cooling sys,
incl install of controls regulated by
this code.
1 MCSUSHTR Commercial In:tall/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted L.nit heater.
1PGASCOM Commerical for ea gas piping System P
1-4 outlets
1 BPGAS For each gas piping system of 5 or P
more per outlet.
1MCAPPVNT Commercial for the install/relocate/ or M
replacement of-.a appliance vent
installed ¬ .ncl in an appliance
permit.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Commercial Seismic B
1 MRRAA Residential Rep air/Alteration/Add to M
ea heating appliance,refrigeration unit,
cooling unit,abs orption unit,or ea
heating,cooling,absorption or _
evaporative coc ling system,incl
installation of controls regulated by
this code.
1MRSUSIATR Residential Install/Relocate ea M
suspended heator,recessed wall htr, or
floor mounted unit heater.
CITY OF CUPERTINO
f
FURNACE/AC
CUPEf�TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
AIR FURN/AC
CONDITIONING
1 BCAIRHAN Commercial A/C Units <= l Ok CFM B
1MCRAA Commercial Mech Repair/alt/add M
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1 BSEISMICO Seismic Commercial B
1PGASCOM Commerical for 4;a gas piping System P
1-4 outlets
1PGASRES Residential for ea gas piping system P
of 1-4 Outlets
1BPGAS For each gas piping system of 5 or P
more per outlet. 'omm/Resid
1 BREMAIRHAN Residential A/C units<= l Ok CFM B
1MRRAA Residential Mec:i Repair/alt/add M
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
f TYPES
1BSEISMICR Seismic Residential B
IEPERMITFEE Electric Permit E
1MPERMITFEE Mechanical Pennit M
1PPERMITFEE Plumbing Permit P
1 TRAVDOC Travel Docume:ltation B
1BUSLIC Business Licen,.e B
INPUT Rescurces Energy •!
1.Windows
1.Install energy-Eff cierd WindD rs
a,13009•Paned I Energy pt y=yes 0
b.Low- Mity t-Ej ?Energy pts y=Yes 0
c.Low.Codc"Fumes ?Energy pts Y=Yes 0
2.Install Low Heat Transmission Glazing I Energy pt y=yes 0
■ 1 1 1
J.Heating Ventilation and Air Conditioning
1.Use pact Mastic on AN pact Joints 2 Energy pts Y--yes
0
2.Install Ductwork within Conditioned Space 3 Energy pts y=yes 0
3.Vent Range Hood to the Outside t IAQ/Health pt y=yes 0
4.Clean all Ducts Before Occupancy 2 IAQ/Health pts y=yes 0
5.Install Solar Attic Fan 2 Energy pts y=yes 0
6.Install Attic Ventilation Systems 1 Energy pt y=yes 0
7.Install Whole House Fan 4 Energy pts y=yes f/ 0
8.Install Sealed Combustion Units
a.Furnaces 3 IAQ/Health pts y=yes 0
b.Water Heaters 3 IAQ/Health pts y=yes 0
9.Replace Wall-Mounted Electric and Gas Heaters with
Through-the-Wall Heat Pumps 3 Energy pts y=yes 0
10.Install 13 SEER/1 I EER or higher AC with a TXV 3 Energy pts y=yes 0
11.Install AC with Non-HCFC Refrigerants 2 Resource pts y=yes 0
12.Install 90%Annual Fuel Utilization Efficiency(AFUE)Furnace 2 Energy pts y=yes 0
13.Retrofit Wood Burning Fireplaces
a.Install EPA certified wood stoves/inserts 1 IAQ/Health pt y=yes 0
b. Install/Replace Dampers 1 Energy pt y=yes 0
c.Install Airtight Doors 1 Energy pt y=yes 0
14.Install Zoned,Hydronic Radiant Heating 3 Energy pts y=yes 0
15.Install High Efficiency Filter 4 IAQ/Health pts y=yes 0
16.Install Heat Recovery Ventilation Unit(HRV) 5 IAQ/Health pts y=yes 0
17.Install Separate Garage Exhaust Fan 3 IAQ/Health pts y=yes 0
oil 1 i 1
K.Renewable Energy and Roofing
1.Pre-Plumb for Solar Water Heating 4 Energy pts y=yes 0
2.Install Solar Water Heating System 10 Energy pts y=yes 0
3.Pre-Wire for Future Photovoltaic(PV)Installation 4 Energy pts y=yes 0
4.Install Photovoltaic(PV)System
(1.2 kw=6 points,2.4 kw=12 points,3.6 kw=18 points) Up to 18 Energy pts 0
6.Select Safe and Durable Roofing Materials 1 Resource pt y=yes 0
7.Install Radiant Barrier 3 Energy pts y=yesI 1 0
1 1 1
L.Natural Heating and Cooling
1.Incorporate Passive Solar Heating 5 Energy pts y=yes 0
2.Install Overhangs or Awnings over South Facing Windows 3 Energy pts y=yes 0
3.Plant Deciduous Trees on the West and South Sides 3 Energy pts y=yes 0
INPUT RLscurres Energy AO
M.Indoor Air Quality and Finishes
1.Use Low/No-VOC Paint 1 IAQ/He Jth pts y--yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3.Use Low/No VOC Adhesives 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
7.Seal all Exposed Particleboard or MDF 4 IAQ/Health. pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes
S.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
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring 6 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:j 1 1401 130 57
Total Points Project Received: 1 01 01
G:data/pneenbuildingguidelines/remodelers/greenpointsfina1212.04protected.xls
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 #
OWNER'S NAME: lv i PHONE # Y S
GENERAL CONTRACTOR: FAX#
I am not using any subcontractors:
Signature Date
Please check applicable subcontraefors and complete the 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
Date
er/Contractor Signature