09020078 CITY OF CUPERTINO nn T
BUILDING DIVISION PERMIT � � A�
BUILDING ADDRESS: PERMIT NO.
8051 PARK VILLA CIR TBD T
OWNER'S NAME: PERMIT ISSUE DATE
PHON S A CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
200 LICENSED CONTRACTOR'S DECLARATION
Iw firm that I am licensed under provisions of Chapter 9(commencing Job Description
Z w with Section 7000)of Division 3 of the Business and Professions Code.and my license is
'=y in full foree leffect. Z V6B POOL COMPLIANCE
5121 License Clas Lic.><
Fe Dale Contractor **COOL POOL SERVICE INC HAS BUS LIC #30645
ARCH S DECLARATION
1.
Inns use u public rxorda
�yU
U.f— Licc P al
n rn OWNER-BUILDER DECLARATION
I reby affirm that I am exempt from the Contractors License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
4 m� which requires a permit to construct,alter,improve,demolish,or repair any structure
y Z r 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
ytom•$ (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 82250
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, 35610093 .POOL
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Cede:The Contractors 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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractors 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 Contractors
License Law.
❑I 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 Workers Compen-
.ton,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 Workers Compensation Insurance,as required by Section
700 of the Labor Code,for the performance of the work for which this permit is issued
My W kee. Co pensation Ins licecarrier and Policy number am:
Cartier. /Polity No.:
CERTIFICATE FEX PTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need Trot be completed if the permit is for one hundred dollars($100)
or less)
I cenify 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z r CONSTRUCTION LENDING AGENCY
[~—h 1 hereby affirm that there is a constntction lending agency for the performance of
pi•� the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
az Lenders Address
U 0 1 certify that 1 have read this application and state that the above information is
LL,h"' correct.I agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
W
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,'dgmcnts,costs expenses which may in any way accrue against said City
V Z in con nce the g g oC this permit.
t APP A DE NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
dke�
S UL
1'7 09 Re-roofs _
Si nature of Applicant/Contractor Da
HAZARDOUS MATERIALS DISCLOSURE Type of R)of
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
Code.Section 25532(a)? p' All roofs.,hall be inspected prior to any roofing material being installed.
❑Yes
l If a roof i,, 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.
trio?
❑Yes �Io
I have re za
e hard</us materials requirements under Chapter 6.95 of the Califor-
nia Hcalth&S cC ore 25505 25533 and 25534.1 understand that if the building
docs not c y h a tenant tha ' my responsibility to notiry the occupant of the
require nus hi list be met r to issuance of a Certificate of Occup ry.(� Signature A Applicant Date
0 9 rr ..
owner ,cd agent D tc All roof coverings to be Class , or better
09 O'� 00 7-0
tat
CITY OF CUPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # �� 3 Date:
Building Address:
&V V VM, ar6jqr aeVA, b qgy y
Mailing Address (if different from building address): ( I
a1 9 3 s b
Owner's Name: � � {-P (�� one #: �g �S� i 17 ?
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from HOA
Contractor: / Phone: 6 Sp q 2 4 3 5-
Fax: (-Sv qct-(
Contractor License#: k{ q D 9 L5 ( �
Cupertino Business License#: ` `' q
Contact: Phone: s� Zf 3 3
Fax: lPsb 9�c 83 L$
Residential ❑ Commercial
Job Description:
V 6 e P014 t6uy
CO—
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, I-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B
Valuation: Square Footage:
Project Size: Express Standard ❑ 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.builditgreen.or
Revised 02/05/09
CITY OF 16UPERTINO
Cin Of GENERAL BUILDING APPLICATION
CUPEkTINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Des,-.ription 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 Wii idow-structural shear B
wall/masonry(includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
1PPERMITFEE Plumbino,Permit Fee P
1 ELCPLNCK Stand A,one Electric Pln Ck (hourly) E
1 MECPLNCK Stand A:one Mechanical Pln Ck (hrly) M
1PLMBLNCK Stand A.one 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
1 BCBSC Cal Bld; Standards Commission Fee B ALL PERMIT
TYPES
1 BSEISMICR Seismic Residential B
/ 1 BSEISMICO Seismic Commercial B
1TRAVDOC Travel &,Documentation B
1 BUSLIC Busine:s License
B
5 of 5
INPUT Resources Energy IAQ/Health
M.Indoor Air uality and Finishes
1 AQ/Health pts y=yes 0
1.Use Low/ND-VOC Paint 0
2.Use Low VOC,Water-Based Wood Finishes 2 AQ/Health pts y=yes
3.Use Low/No VOC Adhesives
31AQ/Health pts y=yes 10
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea 0
Formaldehyde 61AQ/Health pts y=yes
Y 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQMpts is Y= es 0
7.Seal all Exposed Particleboard or MDF 4 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
■ i i 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
E IAQ/Health is es 0
4.Install Natural Linoleum in Place of Vinyl P Y=Y 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
. i i i
Total Points Available: 140E-- 1301 57
Total Points Project Received: 01 0 DO
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