09050044 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � � I� � �Nf
BUILDING ADDRESS: PERMIT NO.
10591 JOHNSON AVE E & I CENTRAL-11FATING Fx ALE 090"10044
OWNER'S NAME: PERMIT ISSUE DATE
Cl?TTTI-%jAjj T7 i\T1r
NE: SXmyAAt. CONTROL NO.
(510) 315-7312
ARCHI7ECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a 0 a 0
a0C LICENSED CONTRACTOR'S DECLARATION Job Description
V I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business and ftfiessionirAA,and my license is
=y in full force andPenCTti Q-1-is ADD A/C 4 TON, 14 SEER & 30AMP CIRCT _
Z License Class c.g
Fq
Date S i t3 Contractor
W ARCHITECTS DECLARA
` 77 1 understand my plans shall be used as public
in Licensed Professional
rn 3 OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
a O following reason(Section 703 L5,Business and Professions Code:Any city or county
$fl! which requires a permit to construct.alter.improve,demolish,or repair any structure
14 prior to its issuance,also requires the applicant for such permit to file a signed statement
Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
YF (commencing with Section 7000)of Division 3 of the Business and Professions Code)tar 6 3 9 8
A that he is exempt therefrom and the buil 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($500). 37527011 . 01
❑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 docs not apply m an owner of q I)
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(See.7044,Business and Professions Code:)The Contractoes 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.
❑I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirrn under penalty of perjury one of the following declarations:
have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
-tion,as provided for by Section 3700 of the Labor Code,for the performance of the
wort for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the wort for which this permit is issued.
My Workeees (ompensadon Insurance carrier and Policy number are:
Carrier. Policy No.:W E 63 00 0 0 L(kV L
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section Treed 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 I hereby affirm that there is a construction lending agency for the performance of
a the work for which this permit is issued(Sec.3097,Civ.C.)
W ALender's Name
0 z Lendces Address
IJ 0 1 certify that I have read this application and state that the above information is
LL t� cored.I agree to comply with all city and county ordinances and state laws relating to
O Vbuilding 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
try rA liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. C
►. APPLICANT U ERS WILL COMPLY WITH ALL NON-POINT Issued by Date
SOURCEREGULA ST
tis Re-roofs
Signature of Applicant/ ontrac r D°le T of Roof
H US MA 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(x)? All roofs Shall be inspected prior to any roofing material being installed.
[:]yes
If a roof i;installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
i hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Arict?
❑Yes �'No
1 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 c ve ant,that it is my responsibility to notify the occupant of the
requi ts hr l p' to issuance of a Certificate of Occas ancy Signature of Applicant Date
All roof coverings to be Class'n'or better
Owner or utho'xcd agent Date
Oq o 0,/L/
CITY OF CUPERTINO
T FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN # I!D ' Date: f 4y
Building Address:
105,C11 �o��sa� AVE
Owner's Name: Phone#:
S1'i►A i Vr"SXf J 1 A*kAP =J oto k, Z 31 . 9dV/
Contractor: Phone#: S1 a,9 y f.-?o u2._
C— aFax#: 5-to, z4v/. i 317.7
Contractor License#: Cupertino Business License#:
Contact: Phone#: 510 , q q 1 . -7ouZ
3aV4,g2n►s
Fax #: S•v.
Building Permit Info:
Elect 9 Plumb Mech
Residential Commercial ❑
Job Description: ,
1aJ� AIG �� , 1'-I SL�2 S130�.--P Cir«. �-
For Residential Installations:
Attic r-11St floor 9 2°d floor ❑
Adhere to minimum setback requirement 12
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction (Usage Class):
Strapped On Platform El Bonded New Location Replacement Ef
Project Size: Express Eg- Standard ❑ Large Major❑
Valuation:
b, 358 .00
Green Building: Please complete relevant portio:i of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index. Cl .
Revised 01/07/09
CITY OF CUPERTINO
FURNACE/AC
CUPEI�TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
AIR FURN/AC
CONDITIONING
1 BCAIRHAN Commercial A/C Units <= l Ok CFM B
1 MCRAA Commercial Mech Repair/alt/add M
1 BCBSC Cal Bldg Standarc s Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Seismic Commercial B
1PGASCOM Commerical for ea gas piping System P
1-4 outlets
1PGASRES Residential for ea gas piping system P
of 1-4 Outlets
1BPGAS For each gas piping system of 5 or P
more per outlet. C omm/Resid
1BREMAIRHAN Residential A/C units<= IOk CFM B
/ 1 MRRAA Residential Mech Repair/alt/add M
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
IEPERMITFEE Electric Permit E
1MPERMITFEE Mechanical Perrr.it M
1PPERMITFEE Plumbing Permit P
1 TRAVDOC Travel Documentation FB—
IBUSLIC
Business Licensc B
M.Indoor Air Quality and Finishes
1.Use LOAWVOC N" , 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3.Use Lowfib VOC Adhe*es 31AQ/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
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7.Setif 49wed P.arla 01Mar4 tK AODF 4IAQ/H ealth. 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 0
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes0
. 1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring B Resource pts y=yes 0
2.Use Rapidly Renewable Flooring Materials IResource 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 l Resource pts y=yes 0
Total Points Available: 1 1401 130 57
Total Points Project Received:1 1 01 01 0
G:datalprogs/grei nbuildngguidelines/remodelers/greenpointsfinal2.12.04protected.xls
Community Development
10300 Torre Avenue
'sem, Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
,UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
i n 5 c o 3c, ^^s-o , Ajc 01 OJ-60 `t
OWNER'S NAME: S pro i v r s/,.� IRA m Anl PHONE # Wl-. 1-3 5 .5 0'-/1
GENERAL CONTRACTOR: L d,197 Cz-v „l 14e�f v-j 0-it FAX #
I am not using any subcontractors:
'Si � vS
gnature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSII4ESS 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
NM141
_ �► a5
Ow(effCon4aAor Signature Date