09020091 77777= -777777777777
CITY OF CUPERTINO
BUILDING DIVISION PERMIT GC?`►TI�ACT�T � AtTIQ�N�
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: ry PERMIT ISSUE DATE
Isi0 A CONTROL NO.
510) 786-0455
ARCHITECUENGiNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u O p LICENSED CONTRACTOR'S DECLARATION Job Description
U3 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
CJ with Section 7000)of Division 3 of the Business and Professions Code,and my license is
'':'§H in full force and cn/� g �� INSTL RETROLIT WNDOW IN DINING RM& LVNG RM
Z ucensc Cl!�_ Lic•N
n-a Date Q6r S,6 t t!2 Contractor K- tS: _
ARCHITECT'S DECLARATION 7
I gd< I understand my plans shall be used as public records
DW C
4 wo H Licensed Professional
rn 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 Code:Any city or county
4 m V which requires a permit to construct.alter,improve,demolish,or repair any structure
v Z prior to its issuance,also requires the applicant for such permit to file a signed statement
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
Ja that he is exempt therefrom and the basis for the alleged exemption.Any violation of
83503
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). 31641071 . 00
❑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 Required Inspections
and Professions Code:The Contractor's License Law does 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 Contractor's 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.
❑I am exempt under Sec B&P C for this reason
OwnerDate
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-insum for Worker's Compen-
..tion,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 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 am:
CarrierCe'rn4ec,:ffiry No.:C-Ap61 B 5-OL/U'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(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,l 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 mast
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
z . CONSTRUCTION LENDING AGENCY
F~•h►�-. I hereby affirm that there is a construction lending agency for the performance of _
the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
Z Lender's Address
V 0 I certify that I have read this application and state that the above information is
Lt~ correct.1 agree to comply with all city and county ordinances and state laws relating to
0V building construction,and hereby authorim representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
i7 h (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
U Z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGU TIONS.
04 AF/57 ef Re-roofs
Signature of Afilicant/C96Lract9f DateT of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
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 roo.'s shall be inspected prior to any roofing material being installed.
❑Yes 0No
Will a roof is installed without first obtaining an inspection,I agree to remove
ll the applicant or future building occupant use equipment or devices which
nit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
istrict?Y
❑Yes ONo
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements hich must be met prior to issuance of a Certificate of Occas ry. Signature Of Applicant Date
z OZ `e `� All roof coverings to be Class'W'or better
Own r or authorize agent Date
(Io D aog
i
CITY OF CUPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
Date: ;
APN # 3 � � � c>� ( � �C7 0-0
Building Address:
Mailing Address (if different from building address):
Owner's Name: _ Phon #:
� :��r /, e v-c/ eV) , -- 3 Zel 7
Contractor: Phone:
Fax:
Contractor License#: G e7(J
Cupertino Business License#:
Contact: Phone:
Fax:
Residential Ej, Commercial El
Job Description: �' -jr& e-r? e-6 ,17�r r
Building Permit Info:
Bldg ±__ Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/IIUV-A ❑ II/III B, IV-HT, `"-B 12 e3
Valuation: _ of Square Footage:
Project Size: Express E3--Standard ❑ Larg,, ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set& the sheet index.
Points Achieved: ?
For help, contact Build it Green at www.buildreen.or
Revised 01/07/09
CITY OF CUPERTINO
In of GENERAL BUILDING APPLICATION
CUPEkTINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee De icription Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New W:ndow-structural shear B
wall/masonry(includes plan ck fee)
IEPERMITFEE Electrical Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit Fee P
IELCPLNCK Stand Alone Electric Pln Ck(hourly) E
1MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-;stand alone
/ 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
I TYPES
/ 1BSEISMICR Seismic-Residential B
1BSEISMICO Seismic- Commercial B
/ 1 TRAVDOC Travel & Documentation B
1 BUSLIC Business License B
5 of 5
M.Indoor Air Oualfty and Finishes
1.Use LowlNo-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 LowlNo 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
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes
7.Seal all Exposed Particdeboard 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
1 1
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 0
1 1 1
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
1 1 !
Total Points Available: 1 1401 13057
Total Points Project Received: 0) 1 01 01 0
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