09020066 CITY OF CUPERTINO
BUILDING DIVISION PERMIT .
: ..;:
PERMIT NO.
BUILDING ADDRESS:
PERMIT ISSUE DATE
OWNER'S NAME: COMPANY
A 2089 CONTROL NO.
UTT c1✓
408 6D5-820
BUILDING PERMIT INFO
ARCHI TECf/ENGINEER:
BLDG ELECT PLUMB MECH
0 (_ [�
u p p LICENSED CONTRACTOR'S DECLARATION Job Description
m I 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
o<a in full force and effect. RPLC 3 NNDWS & 2 DRS W/NEW INTO EXSTNG :.OPENINGS—
D 2gZ License Class 3 Lic.r SZD7 FIS
E p Date '-/ Contractor wM H f2{ �'�
ARCHITECT'S DECLARATION
I 1 understand my plans shall be used as public records
D U
l'o WLicensed Professional
y S OWNER-BUILDER DECLARATION
I hereby affirm that I 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
$
8! which requires a permit to construct.alter.improve,demolish,or repair any structure
y"0 prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
_ZZs< that he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9 Sq.Ft.Floor Area
F (commencing with Section 7000)of Division 3 of the Business and Professions Code)ur
4135— that he is exempt therefrom and the basis for the alleged exemption.Any violadon of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
net more than fire hundred dollars(M). 36930004 . 00
❑I,as owner of the property,or my employees with wages as their sole compensauon,
will do the work.and the structure isnotintendedorofferedforsale(Sec.7au,Business Required Inspections
and Professions Code:The Contractor's license Law does 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,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 conuactor(s)licensed pursuant to the Contractor's
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 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.
❑I have and will maintain Worker's Compensation Insurance,as inquired 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 Politynxmbcr am:
C,mer:C_-1vG PAPaz r t Policy No.; q 7 SSSS G
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,I shall not
employ any person in any manner so as to become subject to the Workcrs'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 shalt be deemed revoked.
z OCONSTRUCTION LENDING AGENCY
E~•t rA I hereby affirm that there is a construction lending agency for the performance of
(y� r7 the work for which this permit is issued(Sec.3097,Civ.C.)
QLender's Name
12� Lendees Address
U 0 1 certify that I have read this application and state that the above information is
It," correct I agree to comply with all city and county ordinances and state laws relating to
0 V building consuuction,and hereby authorize representatives of this city to enter upon the
W ahove-mentioned property for inspection purposes.
96 (We)agree to save,indemnify and keep harmless the City of Cupertino against
,4,t In liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit
r� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b): Date — v
SOURCE REGULATIONS.
/-V-r Z'/3-0? Re-roofs —
Signature of A plicant/Contraclor Dare T 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
Cale,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
fi
❑Ya
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
OR hazardous air contaminants as definedby the Bay Area Air Quality Management all new r iaterials for inspection.
istrict?
❑Yes u
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Cole,Sections 25505.25533 and 75534.I understand that if the building
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements whiph must met pranee of a certificate of Occupancy. Signaturc of Applicant Date
e All roof coverings to be Class"{`'or better
Owner or authorized agent Date
CITY OF 4,UPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN# � �� Date: 2-
S.o
Building Address:
Mailing Address (if different from building address):
Owner's Name: Phone#:
A 1:5t q 6- U 8 -7-1
Contractor: Phone: q,,g 6015- zoo
Fax: �-Sr 913 L- IR 17 3
Contractor License#: zo -7S-S
Cupertino Business License#: Z 8-76--7
Contact: Phone: 6,0 5 v z vo
�11� Fs/7
Fax: 3
Residential Commercial ❑
Job Description:
PLY-)"
I iv7v Lk�S Tire OPE✓` %"'GS
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 [Zj- p
- 3
Valuation: o� 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.buildiW een.or
Revised 01/07/09
4 CITY OF CUPERTINO
UN OF GENERAL BUILDING APPLICATION
CUPEt�TINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description 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 Wir.dow-structural shear B
wall/mas.)nry(includes plan ck fee)
1 EPERMITFEE Electrica Permit Fee E
1MPERMITFEE Mechanii;al Permit Fee M
1PPER.MITFEE Plumbing;Permit Fee P
1 ELCPLNCK Stand Al ane Electric Pln Ck (hourly) E
1 MECPLNCK Stand Al ane Mechanical Pln Ck (hrly) M
1PLMBLNCK Stand Alz)ne Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-s1 and alone
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Pesidential B
1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel &;Documentation B
1
1BUSLIC Business; License B
5 of 5
IAWHealth
M.-Indoor it Quality andfinishes
1.Use LowMo-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
B.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 B 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 i 1
Total Points Available: 1 140 1301 57
Total Points Project Received: _U1 01 0 0
G:data/progs/gn enbuildngguidelines/re odelers/gre poin ina .04protected.xis
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10351 San Fernando Avenue z
Cupertino,CA 95014-2832
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