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09020046 CITY OF CUPERTINO BUILDING DIVISION PERMIT - PERMIT NO. BUILDING ADDRESS: ORT PERMIT ISSUE DATE OWNER'S NAME. A�48CONTROL NO. -HO (888) 657-6527 BUILDING PERMIT INFO ARCHITECifENGTNEER: BLDG ELECT PLUMB MECH ed app LICENSED CONTRACTOR'S DECLARATION Job Description gC 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing m with Section 7000)of Division 3 of the Business and Professions Code,and my license is y in full force and fecL SVC REF LCMNT, 2 CAMP MN BRKR RPLCD, AF Z BRKRS ��z ucenaccl s - Lle. '75JE 1�q POSSBLE FOR BDRMS Date Contractor ice_ /� BCH S DECLARATION -� yundemntand tfly puts d as public records JWUtK ProfessionalOWNER-BUILDER DECLARATION hereby alTirm that 1 am exempt from the Contractofs License Law for the Og reason.(Section 7031.5,Business and Professions Code:Any city or county y ff which requires a permit to construct,alter,improve,dcmolLsh,or repair any structure prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation 2 G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq (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 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($500). 359220E,6 . 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 m 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,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. ❑1 am exempt under Sec B&P C for this reason 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- an,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 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 s compensation Insurance carrier and Policy number are: T Carrier. I 1 sACTOZ(A N Policy No.:_8Z IO 10'2—21SId/3 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or Icss) T 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 ,J O forthwith comply with such provisions or this permit shall be deemed revoked. Z " CONSTRUCTION LENDING AGENCY Fr rA 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.) to Q Lender's Name ]Z L.cndees Address U 0 1 certify that I have read this application and state that the above information is GLHcorrecL I agree to comply with all city and county ordinances and state laws relating to V building construction,and hereby authorize representatives of this city to enter upon the Uabove-mentioned property for inspection purposes. W (We)agree to save,indemnify and keep harmless the City of Cupertino against „Fy liabilities,judgments,costs and expenses which may in any way accrue against said City l C.)Z in co goence of the granu ofYOUL DateAP CANT UNDE TDSWILL COMPLY WITH ALL NON-POINT Issued by: S REGULA ! 6 Re-roof: Si tureofApplicant/Comractor are T of Roof HAZARDOUS MATERIALS DISCLOSURE Type Will the applicant or future building occupant store or handle hazardous material defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety rode,Section 25532(a)? All roof;shall be inspected prior to any roofing material being installed. ❑Yes 3-No 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 it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. riot? ❑Yes Liu 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sects 505,25 3 and 25534.1 understand that if the building docs urrently have a an i i ' responsibility to notify the occupant of the r qu1 m rats which m a tai uance of a Certificate of Gccq-rL- Signature of Applicant Date All roof coverings to be Class'tW'or better Ow or authorized agent Oq c> C,- 0 tat CITY OF CUPERTINO CUPEkTINO GENERAL BUILDING PERMIT APPLICATION FORM APN # � �� � � � � ` � � Date: C Building Address: (.Mai /0 `7A !- C2L1 1uE C-( - Mailing ling Address (if different from building address): Owner's Name: LLL j Phone#: 0400 __ HOA: (Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA Contractor: QED Phone: (SES' Sa&- CVGS Fax: Contractor License#: 757 p l Lf Cupertino Business License#: Contact: CCLJOI STEy'IV Phone: -(C�—, Fax: Residential [g"' Commercial ❑ Job Description: -S& U(C C [2 PLACE/-[C`kjT �Y. /� �"( J� ► ,(� I i�/201) t)c. (- !b 1C- C0 / i 1F- ' ,�� i�a ,lt S Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B � C Valuation:f(a.! X00 V 0 Square Footage: Project Size: Express L;--!§-tandard ❑ Large 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.builditar!en.or Revised 02/05/09 CITY OF CUPERTINO Cin of GENERAL BUILDING APPLICATION CUPEkTINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additiona: stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windows) 1 WINMEWSTR New Window-structural shear B wall/masonry(includes plan ck fee) / 1 EPERMITFEE Electrical Permit Fee E 1 MPERMITFEE 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 Standarc.Plan Check (when no E/M/P) B when not over counter) hourly-s Land alone 1 1 BCBSC Cal Bldl;Standards Commission Fee B ALL PERMIT TYPES i I BSEISMICR Seismic Residential B i 1BSEISMICO Seismic Commercial B 1 TRAVDOC Travel &Documentation B IBUSLIC Business License B 600 P -L 0,(j 5 of 5 INPUT Resources • IAO/Health M.Indoor Air Oualfty and Finishes 1.Use Low/No-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 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 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 7.Seal all Exposed Particleboard 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 10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 0 N.Flooring 1.Select FSC Certified Wood Flooring 3 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 130 57� Total Points Project Received:1 1 01 01 0 G:data/progs/gree:nbuildingguidelines/remodelers/greenpointsfina12.1204protectedxls Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CIV OF Fax(408)777-3333 CUPEkTINO Building Department JOB ADDRESS: PERMIT # OWNER'S NAME: 0 co 1 c_t_C PHONE # GENERAL CONTRACTOR: RCL Sc�)LA2. FAX # I am not using any subcontractors: =(--\ -'a 1/0 Signature ate Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSI14ESS 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