09020079 CITY OF CUPERTINO
BUILDING DIVISION PERNIIT � � �� ' `
BUILDING ADDRESS: PERMIT NO.
805 SURREY CT TBD - TD BE D
OWNER'S NAME: PERMIT ISSUE DATE
ON
siAgrtAitytt.2CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 � 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
'cH inmHforceand O Z V6B POOL COMPLIANCE
Z License Cl ., Lic.x
E-Z Date Con r **COOL POOL SERVCE INC PD FOR BUS LIC
A CT LARATION
J g d I un nd y all be blit records
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y u.
C y Llcensc ron.
OWNER-BUILDER DECLARATION
i he that I am exempt from the Contractor's License Law for the
p O following rtion 7031.5,Business and Professions Code:Any city or county
K Pi which requires a permit to construct,alter,improve,demolish,or repair any structure
y Z prior to its issuance.also requires the applicant for such permit to file a signed statement
F that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
y F$ (commencing with Section 70)0)of Division 3 of the Business and Professions Code)or 12
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
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). 34233012 POOL
❑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 ns Required Inspections
and Professions Code:The Contractor's License Law docs 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.
❑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 Workers Compen-
..ation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
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 Worke(/�s Co pensatian Inj�y�ice/carrier and Policy number are:
Carrier r /� `L� tlicy No.:
CERTIFICATE O EXF�MPTION FROM WORKERS'
COMP SATION 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 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
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
(� I hereby affirm that there is a construction lending agency for the performance of
p, the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lenders Name
aLenders Address
V 0 I certify that I have read this application and state that the above information is
(L t'" toren.I agree to comply with all city and county ordinances and state laws relating to
OV building construction,and hereby authorize representatives of this city to enter upon the
Ula. above-mcmioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judg s, sts and a nses which may in any way accrue against said City
V z in conseque c rami this Permit. Date
t APPLIC R SAND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUR TI
Re-roofs
rgn of Applican Contractor are
HAZARDOUS MATERIALS DISCLOSURE Type of F.00f
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)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes o
If a roof;s installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
tat hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
.strict?
❑Yes Wo
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hcallh&Safety Codc,Sections 25505.25533 and 25534.1 understand that if the building
docs n Trent ve a tenant. a is my responsibility to notify the occupant of the
icytnts is must be or to is,
of a Ccnificatc of cnp cr. Signature of Applicant Date
All roof coverings to be Class'A'or better
O n or authorixcd agent Dare
09
tat-, CITY OF C:UPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
Q� o�-
APN # 33 d Iobi ate: t e-,2-4*7
Building Address: 11
ZZ S C �R`L't�U
Mail g Address (if different from building
0 Ca►s,•w ,' 9 3S Crc�(L oP� S 3
Owner's Name: �a64 Phone#: to e Ss 9 1Q?,0
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from HOA
Contractor: �l Phone:
Fax: 05,0 f y-t -9 3 Z '
Contractor License#: `190 q2--,5-
Cupertino
2SCupertino Business License#:
Contact: -v� b Phone: OS-09 q
JA
Fax: (o SV F(( l
Residential ❑ Commercial
Job Description:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B El II/III/V-A El 11/111 B, IV-HT, V-B ❑
Valuation: ,,,,o Square Footage:
.-I 2
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.builditut een.or
Revised 02/05/09
CITY OF CUPERTINO
0"Of GENERAL BUILIIING APPLICATION
CUPEI�TINO
FEE S(:HEDULE
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 Window-structural shear B
wall/masonry (includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
/ 1 PPERMITFEE Plumbin€;Permit Fee P
1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1 MECPLNCK 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-st�md alone
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1 BSEISMICR Seismic F:esidential B
/ 1 BSEISMICO Seismic Commercial B
/ 1 TRAVDOC Travel & Documentation B
IBUSLIC Business License B
5 of 5
Green Building Plan Check
Index of Green Building Points/Categories
A. Category Example of an Index or Table of Green Plan Sheet or Page Points
Building Points Categories that mu:;t be
shown and referenced on the Project
Plans See below INNER 111,111 11111MMM1
B. Site 9. Install H.E. Irrigation, (details/spec)' L-1 2 points
11. Permeable Paving, Note L-1 2 oints
C. Foundation 1. Use 15 % Flyash Concrete, (nota) S-1 5 points
D. Structural 3. Uses Wood I-Joist, (See Spec.) S-2 2 points
5. Use Truss with heels, (detail) S-2 2 points
6. B. OSB Sheathing, (detail) S-2 2 points
E. Ext. Finish 1. Composite Decking, (Note/Spec) A-3 2 points
4. B. Fiber Cement Siding, (Note/Spec. A-4 2 points ,
F. Plumbing 1. Insulate all H.W. pipes, (Note/Spec.) P-1 2 points
5. Tankless W.H., (Note/Spec.) A-2 2 points
11. A 2500 Gal.Tank, (Note/Spec L-1 10doin
G. Electrical 4. E. Ceiling Fans, (Note/Spec.) A-3 4
H. Appliances 1. Energy Star Dishwasher, (Note/:3pec.) A-3 1 3. Ener Star Refrierator, Note/3 ec. A-3 1P. Other 1. List Green Features on Plans A-1 1 RMIKIN TOTAL FOINTS 40
Plan Review Process Work Book Page-12-Revised 3/25/08