09040128 CITE'OF CUPERTINO ��^rt �•c .�+ �t
BUILDING DIVISION PERMIT l � R�LI � 1 #�.
PERMIT NO.
BUILDING ADDRESS:
10555 MARY AVE CITY OF
PERMIT ISSUE DATE
OWNER'S NAME:
S A CONTROL NO.
!N
BUILDING PERMIT INFO
ARCHITECr/ENGINEER: BLDG ELECT PLUMB MECH
y p C LICENSED CONTRACTOR'S DECLARATION Job Description
IU C 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z it with Section 7000)of Division 3 of the Business and Professions Code,and my license is
n`D RPLC 4 :?RCELN STND—AEON SNKS W/4 SNK INTGRTD
in full force and effect.
C-z F„O Date Contractor
LM•gtc Contractor COUNTR t4/SENSR FAUCETS& MV SNGL GFI& ADD ANOTHR
In ARCHITECTS DECLARATION
g-1 I understand my plans shall be used as public records GF I
�aU
`Wo y Licensed ProCcssional
rn OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
y:� which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq
X I- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
86000
4192 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 fire hundred dollars($5M. 32606052 MENS
❑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 Contractors License Law docs 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.).
❑I,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 r _ ,B&P C fo this ason
Owner „ '�` � _ Date 1 °�.3 )77n
WORKER'S¢ MPENSA71ON DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
J I have and will maintain a Certificate of Conscnt to self-insure for Worker's Compen-
sation,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 Workers Compensation Insurance carrier and Polity number are:
Cartier. Policy No.:
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 thew0;;-,
rk fo (yhich this permit is issued,I shall not
employ any person in any manner so as to c subject to the Workers'Compcnsatian
Laws oC Califomi
Applicant
NOTICE TO APPLICANT:If,after ng this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Codc,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
tY, the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lenders Name
z Lenders Address
V C) I certify that I have read this application and state that the above information is
LL�' corccL I agree to comply with all city and county ordinances and state laws relating to
0 CF.j building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments,costs and expenses which may in anyway accrue against said City /�
V Z in consequence of the granting of this permit Date Z_ 5
r--c APPLICANT U ERSTANDS AND,WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE EGU ONS. ��
Re-roofs —
S1gnatum.fAppT..__UConua Date
HAzAKDOUS MATERIALS DISCLOSURE Type of Loof
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.
❑Ya No ,.
Will a roof s installed without first obtaining an inspection,I agree to remove
ill the applicant or future building occupant use equipment or devices which
At hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
mquiremen which m be met poor to i trarke of a Certificate of Oc ancy. Signature of Applicant Date
c:,
z 3 v �L All roof coverings to be Class r' "or better
Owner or authorized agcm ,,l Date
tt- CITY OF C-.UPERTINO
CUPEkTiNO GENERAIJ BUILDING
PERMIT APPLICATION FORM
APN # /) . /27 Date: zll-�3
Building Address:
OSS S �� �u r /,Ll
Mailing Address (if different from building address):
Owner's Name: / vi Phone#:
HOA: (Exterior work only) Yes ❑ No ❑ 0-3
If yes, provide letter from HOA
Contractor: �¢ Phone:
Fax:
Contractor License#:
Cupertino Business License
Contact: Phone:
E��/c.-✓ �cis' - r��.3
Fax:
Residential ❑ Commercial
Job Description: Per 14 C-e- I Pv('r.P�• s
Building Permit Info:
Bldg ❑ Elect ..LJ— Plumb-��~ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A F1II/III B, IV-HT, V-B ®i r w
Valuation: a v 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
1
• CITY OF CUPERTINO
Cin OF GENERAL BUILDING APPLICATION
CUPEkT1N0
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1BBOILERI For the insta.lation or relocation of ea M
boiler/comps essor to & including 3
horsepower, or ea absorption sys to &
incl 100,000 Btu/h (29.3kw)
1 BBOILER2 Installation/relocation of ea M
boiler/compressor over 3 horsepower
to & incl 15 horsepower, or ea
absorption s-✓s over 100,000 Btu/h
1 BBOILER3 Installation/i elocation of ea M
boiler/compressor over 15 horsepower
to & incl 30 horsepower, or ea
absorption s,s over 500,000 Btu/h to
& incl 1,000,000 Btu/h
1BBOILER4 Install ationh•elocation of ea M
boiler/comp:-essor over 30 hosepower
to & incl 50 horsepower, or for ea
absorption s�s over 1,000,000 Btu/h to
& incl 1,75C,000 Btu/h
1BBOILER5 Install ationh-elocation of ea boiler or M
refrigeration compressor over 50
horsepower, or ea absorption sys over
1,750,000 Btu/h
1 BAPPLOTH For ea appli;mce or piece of equip M
regulated by this Code but not classed
in other app:iance categories, or for
which no other fee is listed in this
code.
1 ELECINSP Other Electrical Inspections (per hour) E
1MECHINSP Other Mechanical Inspections (per M
hour)
1PLMBINSP Other Plumbing & Gas Inspections P -
(per hour)
1 MEETING 1 HR Application Meeting B
2of5
INPUT Re,;Durces Energy AQ
D.Exterior Finish
1.Use SusWnaibl9 Deplang Materials
a.Recy Wwnta t 3.Resource pts y=yes 0
IL FSC C Mied Wood 3 Resource pts y=yes 0
2.Use Treated WOW That Does Not+COrttot i hrolniurWArse* 1 IAQ/Health pt y=yes 0
3"i Nouse titkap 1 IAQ/Health pt y=Yes 0
4.Use Fiber-Cement Siding Materials 1 Resource pt y=yes 0
E.Plumbing
1.Install Water Heater Jacket 1 Energy pt y=yes 0
2.Insulate Hot and Cold Water Pipes 2 Energy pts y=yes 0
3.Retrofit all Fauoets and Showerheads with Flow Reducers
a.Faucets(1 point eat,up to 2 points) Up to 2 Resource pts. 0
b.Showommds(1 point each,up to 2points) Up to 2 Resource pts, 0
4.Replace Toilest with Ultra-Low Flush Toilets
(1 point each,up to 3 points) Up to 3 Resource pts. 0
5.Install Chlorine Filter on Showerhead 1 IAQ/Health pt y=yes 0
6.Convert Gas to Tankless Water Heater 4 Energy pts y=yes 0
7.Install Water Filtration Units at Faucets
(2 points each,up to 4 points) Up to 4 IAQ/Health pts, 0
B.Install On-Demand Hot Water Circulation Pump 4 Resource pts y=yes 0
r,tieccncai
1.Install Compact Fluorescent light Bulbs(CFLs)
(6 bulbs—_2 points,10 bulbs=3 points,12 bulbs=4 points) Up to 4 Energy pts. 0
2.Install IC-AT Recessed Fixtures with CFLs(1 point each,up to
5 points) Up to 5 Energy pts. 0
3.Install Lighting Controls(1 point per fixture,up to 4 points) Up to 4 Energy pts. 0
4.Install High Efficiency Ceiling Fans with CFLs
(1 point each,up to 4 points) Up to 4 Energy pts. 0
. ! i 1
G.Appliances
1.Install Energy Star Dishwasher 1 Energy pt y=yes 0
,2.Install Washing Machine with Water and Energy
Conservation Features 1 Energy pt y=yes 0
3.lnstall Energy Star Refrigerator 1 Energy pt y=yes 0
4.Install Built-In Recycling Center 3 Resource pts y=yes 0
H.Insulation
1.Upgrade Insulation to Exceed Title 24 Requirements
a.Walls 2 Energy pts y=yes 0
b.Ceilings 2 Energy pts y=yes 0
2.Install Floor Insulation over Crawl Space 4 Energy pts y=yes 0
3.Install Recycled-Content,Fiberglass Insulation with
No Added Formaldehyde 3 IAQ/Health pts y=yes 0
4.Use Advanced Infiltration Reduction Practices 2 Energy pts y=yes 0
5.Use Cellulose Insulation
a.Walls 4 Resource pts y=yes 0
b.Ceilings 4 Resource pts y=yes 0
6.Alternative Insulation Products(Cotton,spray-foam)
a.Walls 4 Resource pts y=yes 0
e.uenings 4 Resource pts y=yes 0
1 1 kod
M.Indoor Air Quality and Finishes
1.Use towft-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 Lowft 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 1 0
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 0
EM
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring li Resource pts y=yes 0
2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles .I 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 I Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs I Resource pts y—yes 0
. 1 1 1
Total Points Available: 1 1401 1301 57
Total Points Project Received: 0 O=
G:data/progs/gre+:nbuildingguidelines/remodelers/greenpointsfina12.12.04protected.xls