09040134 7 777
77777 77-7777
CITY OF CUPERTINO
BUILDING DIVISION PERMIT � T � � 4
PERMIT NO.
BUILDING ADDRESS:
20385 VIA PORTOFINO ATLAS-7: ILLO kc
PERMIT ISSUE DATE
OWNER'S NAME:
S A CONTROL NO.
DNE:
(408) 285-8931
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
u p C LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
U 5 with Section 7000)of Division 3 of the Business and Professions Code,and my license is ADD A/C UNIT
2'y in full fora and tier
v�Z License Clas Lle•# -
n rp Date Contractor f Tl I n
ARCHITECTS DECLARATION
J�< I understand my plans shall be used as public records
7yU
O ti Licensed Professional
OWNER-BUILDER DECLARATION
<f 1 hereby affirm that I am exempt from the Contractor's License Law for the
a0 following reason.(Section 7031.5,Business and Professions Code:Any city or county
K which requires a permit to construct,alter.imPrO ,demolish,or repair any swcture
't"w prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
yF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $2700
y .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mere than five hundred dollars(M). 31601098 . 00
0 I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure isnot intended oroffered for sale(Sec.7044,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.).
0 1,as owner of the property.am exclusively contracting with licensed contractors to
construct the project(See.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 contractors)licensed pursuant to the Contractor's
License Law.
0 1 am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self-insure for Workers Compen-
sation,as provided for by Section 3700 of the Labor Code.for the performance of the
work for which this permit is issued.
0 1 have and will maintain Worker's 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 Comp,asation nsurance trier and Policy number are:
Cartier. `�/� Policy No.:`/�� m b
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or Icss.)
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'Compensadon
Laws of California Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workces Compensation provisions of the Labor Code,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
fx the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
az Lendees Address
[certify that 1 have read this application and state that the above information is
U
correct I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
0 W above-mentioned property for inspection purposes.
C>~ (We)agree to save,indemnify and keep harmless the City of Cupertino against
„H,y to liabilities,judgments,costs and expenses which may in any way accrue against said City �J , ,r
V z in consequence C the granting of this permit t Date f Z —I G�1
►, APPLIC E AND WILL COMPLY WITH ALL NON-POINT Issued by-
SOUR ^
)2S Re roofs -
SignatureofApplicant/Contractor Da
HAZARDOUST of Roof /
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Muntci I Code.Chapter 9.12.and the Health and Safety
Cede,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
O Yes
Will the app litanl or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new r-iatenals for inspection.
.,Istria?
OYes
1 have re hazardous materials requirements under Chapter 6.95 of the Califor-
niceHealth& c Sections 25505.25533 and 25534.I understand that if the building
docs not rrendy risibility to notify the occupant of the
require ents w' must or to issuance of a Certificate of Occupancy. S ur'of Applicant
All roof coverings to be Class'n'or better
Own authorized agent Date
CITY OF CUPERTINO
FUIViACE/AC
CUPEkTINO PERMIT APP] JICATION FORM
APN # ') C� �• 6 0
Building,Add r s s-S
Owner's Name: Phone#:
Y"1�1,,'ct o 1?1.3- (),.2,0
Contractor: Ph ne#:
G(
T
L � V�C� Fax#:
Contractor License#: Cupertino Business License#:
�� i
Contact: Phone#:
a�4 1 Fax#:
Building Permit Info:
Elect❑ Plumb ❑ Mech ❑
ResidentialCommercial LJ
-—Y—�
Job Description:
ll
f
For Residential Installations:
Attic ❑ 1St floor [] 2°d floor El
Adhere to minimum setback requirement
For Commercial Installations: tl
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cog Pf Project: Type of Construction (Usage Class):
� t , r
Strapped I On Platform Bonded H New Location Replaceme
Project Size: Express Standard ❑ Large ❑ Major❑ _
Valuation:
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index.
Revised 01/07/09
CITY OF C UPERTINO
FURNA.CE/AC
CITYCUPEf�TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
AIR FURN/AC
CONDITIONING
1 BCAIRHAN Commercial A/C Units <= I Ok CFM B
1MCRAA Commercial Mech Repair/alt/add M
1BCBSC Cal Bldg Standaris Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Seismic Commercial B
1 PGASCOM Commerical for e a gas piping System P
1-4 outlets
1PGASRES Residential for eE gas piping system P
of 1-4 Outlets
1 BPGAS For each gas piping system of 5 or P
more per outlet. ('.omm/Resid
1BREMAIRHAN Residential A/C units<= IOk CFM B
I MRRAA Residential Mech,Repair/alt/add M
1BCBSC Cal Bldg Standaids Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residen,ial B
/ 1 EPERMITFEE Electric Permit E
1 MPERMITFEE Mechanical Permit M
f
1PPERMITFEE Plumbing Permit. P
1 TRAVDOC Travel Documer.tation B
1BUSLIC Business Licens,: B
INPUT Resources Energy IAQ/Health
M.Indoor Air Quality and Finishes
1.Use Low/No-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 LowNo 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 6IAQ/Health pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
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
N.Flooring
1.Select FSC Certified Wood Flooring 3 Resource pts y=yes 0
2.Use Rapidly Renewable Flooring Materials 1 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles t 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 t Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs I Resource pts y=yes 0
Total Points Available: 1 1401 130T-----7571
Total Points Project Received: 01 0 0
v
G:data/prop/gref nbuildingguidelines/remodelers/greenpointsfinal2.12.D4protected.xls
INPUT ResDurces Energy +0
I.Windows
1.Install Energy-Efficient Windows
a.Double-Paned 1 Energy pt y=yes 0
b.Low-Emissivity(Low-E) 2 Energy pts Y--yes 0
c.Low.Conductivity Frames 2 Energy pts y=yes 0
2.Install Low Heat Transmission Glazing 1 Energy pt y=yes 01 1
1 1 1
J.Heating Ventilation and Air Conditioning
1.Use Duct Mastic on All Duct Joints 2 Energy pts y=yes 0
2.Install Ductwork within Conditioned Space 3 Energy pts y-yes 0
3.Vent Range Hood to the Outside 1 IAQ/Health pt y=yes 0
4.Clean all Ducts Before Occupancy 2 IAQ/Health pts y=yes 0
5.Install Solar Attic Fan 2 Energy pts y=yes 0
6.Install Attic Ventilation Systems 1 Energy pt y=yes 0
7.Install Whole House Fan 4 Energy pts y=yes 0
8.Install Sealed Combustion Units
a..Furnaces 3 IAQ/Health pts y=yes 0
b.Water Heaters 3 IAQ/Health pts y=yes 0
9.Replace Wall-Mounted Electric and Gas Heaters with
Through-the-Wall Heat Pumps 3 Energy pts y=yes 0
10.Install 13 SEER/11 EER or higher AC with a TXV 3 Energy pts y=yes 0
11.Install AC with Non-HCFC Refrigerants 2 Resource pts y=yes 0
12.Install 90%Annual Fuel Utilization Efficiency(AFUE)Furnace 2 Energy pts y=yes 0
13.Retrofit Wood Burning Fireplaces
a.Install EPA certified wood stovesfinserts 1 IAQ/Health pt y=yes 0
b. Install/Replace Dampers 1 Energy pt y=yes 0
c.Install Airtight Doors 1 Energy pt y=yes 0
14.Install Zoned,Hydronic Radiant Heating 3 Energy pts y=yes 0
15.Install High Efficiency Filter 4 IAQ/Health pts y=yes 0
16.Install Heat Recovery Ventilation Unit(HRV) 5 IAQ/Health pts y=yes 0
17.Install Separate Garage Exhaust Fan 3 IAQ/Health pts y=yes 0
K.Renewable Energy and Roofing
1.Pre-Plumb for Solar Water Heating 4 Energy pts y=yes 0
2.Install Solar Water Heating System 0 Energy pts y=yes 0
3.Pre-Wire for Future Photovoltaic(PV)Installation 4 Energy pts y=yes 0
4.Install Photovoltaic(PV)System
(1.2 kw=5 points,2.4 kw=12 points,3.6 kw=18 points) Up to 18 Energy pts 0
6.Select Safe and Durable Roofing Materials Resource pt y=yes 0
7.Install Radiant Barrier 3 Energy pts y=yes D
. 1 1 1
L.Natural Heating and Cooling
1.Incorporate Passive Solar Heating '. Energy pts y=yes 0
2.Install Overhangs or Awnings over South Facing Windows Energy pts y=yes 0
3.Plant Deciduous Trees on the West and South Sides Energy pts y=yes 0
Community Development
" 10300 Torre Avenue
a a, Cupertino CA 95014
Telephone(408)777-3228
CITY OF
Fax(408)777-3333
:UPEkTINO
Buildi:n De artment
JOB ADDRESS: PERMIT #
0 eFa14o
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR:AHazr {f v FAX#
�S
I am not using any subcontractors:
Sig=nature 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
_ C/
Owner/Con ignature Date