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09070043 777777777777-77 CITY OF CUPERTINO BUILDING DIVISION PERNUT PERMIT NO. BUILDING ADDRESS: 11083 NILKINSON AVEANTIQUE RM PERMIT ISSUE DATE OWNER'S NAME: A CONTROL NO. "ON 408) 995-6300 BUILDING PERMIT INFO ARCHI'rBCT/ENGINEER: BLDG ELECT PLUMB MECH a o p LICENSED CONTRACTOR'S DECLARATION Job Description rut I boreby affirm that I am licensed under provisions of Chapter 9(commencing -z m with Section 70(1))of Division 3 of the Business and Professions Code,and my license is 'mu. in full force and L RE-MODL SHOWER STALL, NO ELECT/LIGHTNG/MECH j n? Lice Clara Lam• AfrUrZ 3 f,O Date — Con ryLt r M- ARCHITECT'S DECLAR IO I understand my plans shall be used as public records ryU yO y Licensed Professional 0 Gn OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License law for the C p O following reason.(Section 7(131.5,Business and Professions Code:Any city or county .4 m which requires a permit to construct.alter,improve,demolish•or repair any structure 4;i-- prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Y. Valuation (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 83500 y 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 net more than five hundred dollars(M). 35617036 . 00 ❑I,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 dots 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.). [11.as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044.Business and Professions Code:)The Contractnes 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 Licenseyaw- a f mm 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: 1 have and will maintain a Certificate of Consent to self-insure for Workces Compen- ..hon,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 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 are: Cartier. I.✓-r//_S Fd�-(e Policy No•� ERTIFICATE OF EXEMPTION FRd W RKERS' 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 T•O 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"' CONSTRUCTION LENDING AGENCY [~—r 41 hereby allirm that there is a construction lending agency for the performance of (Y,> the work for which this permit is issued(Sec.3097,Civ.C.) WCs,Q Lender's Name a L.cndee Address V 0 I certify that I have read this application and state that the above information is V." 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 W above-mentioned property for inspection purposes. CL (We)agree to save,indemnify and keep harmless the City of Cupertino against ,E""„t CA liabilities,judgments,costs and expenses which may in any way steric against said City U Z in consequence of the granting of this permit. Date ►" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b) SOURCF REGULATIONS. Re-roofs — gn Applicant/Contractor Dao T of hoof 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 roofs shall be inspected prior to any roofing material being installed. ❑Yes ❑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 hazardous air contaminants as dcfrned by the Bay Area Air Quality Management all new r iaterials for inspection. uict? ❑Yes ❑Nu I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building does not currently have a tenant,that it is my responsibility to notify the occupant of the requirements which must be mel prior to issuance of a Certificate of occupancy. Signaturt;of Applicant Date . 6 r rr �. cr or authorixcd age All roof coverings to be Class J� or better Dare CITY OF CUPERTINO l ADDITION/REMODEL CUPEkTINO FEE SCHEDULE APN # 7 Date: G � Q Building Address: Y Mailing Address (if different from building address): Owner's Name: tj >t y j tj i. c /o c- W rS 7r r N Phone# HOA: (Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA _ Contractor: Phone#: A Fax #: — Contractor License #: P r 11J17 Cupertino Business License#: yA Contact: Phone#: Fax #: Buildin Permit Info: Bldg. El._ Elect. ❑ Plumb. J� Mech. ❑ Hillside ❑ Job Description: Addition-What is being added?(Be Specific): What is being remodeled (not including addition)? ;r. iv0 6 < 7 /Nv Remodel Includes Re-Roof: Yes ❑ No [l If yes list number of squares Remodel Includes Structural: Yes ❑ No [l Do you have the pre-application planning approval? Yes ❑ No If yes, please provide a copy of your plannin approval letter. Planners name: Square Footage: Addition: Porch: Deck: Garage: Detached Attached Remodel: Kitchen Bath Other Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B [f IUIII/V-A ❑ IUIII B, IV-HT, V-B ©r (R-7 Valuation: '3/ s'a 0, Please check this box if the project is a second-story addition F-1Project Size: Express ❑ Standard Large [—] MajorF] Please complete relevant portion of the Green Building Checklist& attach it to the application or if appli-able, Green Building Points Achieved include in plan set& the sheet index. ***For Office Use Only*** 1­1Revised 02/05/09 Over-the-Counter CITY OF CUPERTINO ADDITOISIREMODEL FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Sq Ft Group 1 REMRES2 Remode. Residential B Greater than 1000 sq ft IREMRES3 Remode. Residential B Greater than 2500 sq ft. 1REROOFRES Residential Re-roof Each B 100 SF REMODEL PLNCK ISTPLNCK(1-3 for Standard Plan Check B NOT FOR OVER THE remodel) COUNTERMAN CKS. WINDOW/SLIDING 1R3SFDREM GLASS DOOR 1WINREP Replacement windows B (ea 8 windows) 1 WINNEWNSTR New Window (non- B structural) 1 WINMEWSTR New W:ndow (Structural B Shear Wall/Masonry) 1WINBAYSTR Bay Wi:idow (Structural) B SKYLIGHTS 1R3SFDREM 1SKYL<10 SF Skyligh�less than 10 sf B 1 SKYL>10SF Skylight greater than 10 B sf or structural 1STAIRS Stairs-first flight/ea B addt'1 1EPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M I 1 PPERMITFEE Plumbi zg Permit Fee P 1 ELCPLNCK Stand Mone Electric Pln E Ck (hourly) CITY OF CUPERTINO ADDITON-/REMODEL FEE SCHEDULE Quantity Fee ID Fee De wription Fee Permit Type Sq Ft Group 1MECPLNCK Stand Alone Mechanical M Pln Ck (:burly 1PLMPLNCK Stand Alone Plumbing P Pln Ck (burly) 1 BCBSC Cal Bldg; Standards B ALL PERMIT TYPES Commission Fee / 1 BSEISMICRE Seismic Residential B 1 1 TRAVDOC Travel &Documentation B 1 BUSLIC Busines;> License B INPUT Resources • IAO/Health Indoor Air Quality and Finishes 1.Use Low/No-VOC Paint IAQ/Health pts y=yes 0 2.Use Low VOC,Water-Based Wood Finishes IAQ/Health pts y=yes 0 3.Use Low/No VOC Adhesives ;I 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 6IAQ/Health pts y=yes 0 6.Use Exterior Grade Plywood for Interior Uses IAQ/Health pts y=yes 0 7.Seal all Exposed Particleboard or MDF 4 IAQ/Health. pts y=yes 0 8.Use FSC Certified Materials for Interior Finish t•Resource pts y=yes 0 9.Use Finger-Jointed or Recycled-Content Trim I 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 8 Resource pts y=yes0 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 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 kind Total Points Available: 140 1301 57 Total Points Project Received: 0 G:data/progs/gree ibuildingguidelines/remodelers/greenpointsfinal2.12.D4protected.xls •C-y- ��' `_ ..�� -x-.�'"` Ems-. ,r .-.. -z'�- r���"— .: r -z' -xs '"� :- '- �:^ .+-.��:. �•�'Sr- R --ri�..e_ -�` Y S" „l.� •uist - � J��=i { t_-�' »�}` f-f } 4" �.- k •vr -��-"s v �- 7-'� -s"yr- :-+Z �.� Tr,•..'�. v-aC--'L-� _� „yc e.. �z e" F.: v'. - _,�. Assessor's Parcel Number:-- Name umber: -Name of owner. 4„/,m y LQ i C.j2t r L&,,r e.f t rely, //o Proj ect address. Ltj i L v-eIN i a e, Contact person. L. f, ,•� Q 1 t,° � Phone. -L� 3 by F, x. Net square footage of lot. Existing Proposed Square footage: First floor: _ Second floor: n Garage: TOTAL: Are there at least two 10 foot by 20 foot clear spaces inside the garage? ,rte<N (z privacy protection planting required for the project? i On what floor(s) is work being done? 1Y1,4 !; 6'/ .yrl'. 7A r c ;� -A f� f;,V r e leC Vr �qt< S Sti , rr ��.✓ 3"Lr /'T Ar f 14C t Lv i'f k , N `t Brief description of work.A,,,.g, 3 C i1 ALd r. TA . W max_O m Al ,v t ,,, ;e7 4� A, r u.c� b .f v s.. e del de/,,F, c✓1--4 A Code editions:2008 CBC -N)2008 ��; _1&2008 CMC (Y-N) 2008 CPC ,�� RD�QOES p,NO V 1N0 ,. Effective 1/1/08 U .t B KeU tc� don. x \s�►� e w, ` Sam _ be G" v�_ .gat y�Aw e\' . t any Plan Review Process Work Book Page-B-Revised 1/1/08 �:Mr- IUV2 E�R -72-3��-Z tin- RIN A, 7Z-;C ��-T - 7-i cl, -47, M 7-5, isnt.iR- Z7 MONO -R- Z� !-,44 M % V0 1',- -.5 KMV,� ims A"NP W- Assessor's Parcel Number: Name of owner. J .m V 1',Q 1 j2 L&,r es f r Wo I Project address. it,/I L k- 4. 14 y-e4j Contact person. et p'!4 P�one. c�, ;_z Fix- 7 It — Net square footage of lot. Existing Propose Square footage: First floor: Second floor: Garage: TOTAL: Are there at least two 10 foot by 20 foot clear spaces ir zide the garage? ,-�<N ,3 privacy protection planting required for the project? On what floor(s) is work being done? iing 5,-r6'1� 77A v e.-7-, A r f 14 e r- Pow Brief description of work.4 a 1-CZ�t A-1, 9 A., r- Ze:4,C T 71- A 5,d,r Code editions:2008 CBC 6&-N)2008 CFC N)2008 CMC (Y-N) 2008 CPC N)2008 NEC N) Effective 1/1/08 T Plan Review Process Work Book Page-8-Revised l/l/08 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 -UPEkTINO Building Department JOB ADDRESS: PERMIQ K OWNER'S NAME: - Aft PHONE # - GENERAL CONTRAC OR: — js�z'A,1 FAX # _ b s"/7. I am not using any subcontractors: SigrnalKure Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS 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