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09050117 CITE'OF CUPERTINO BUILDING DIVISION PERMIT �1RAC? t I� R1TI�31t• BUILDING ADDRESS: PERMIT NO. 10042 MOSSY OAK CT CUPERTINO PLILMaIN-G- 09050117 OWNER'S NAME: PERMIT ISSUE DATE PHONE: A O, 8 0 9 CONTROL NO. (408) 253-0618 CHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 o p LICENSED CONTRACTOR'S DECLARATION Job D05CrlpClOn V I hereby affirm that I am licensed under provisions of Chapter 9(commencing Z with Section 70(X0)of Division 3 of the Business and Professions Code,and my license is °'y in full force and ffe COPPER REPIPE va Z License Class Lic. ri N in Date — Contractor /t'v tz ARCHITECTS DECLARAT1614 eat< I understand my plans shall be used as public records �yU L u.y Licensed Professional n y, OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the p Oer following reason.(Section 7031.5,Business and Professions Code:Any city or county which requires a permit to construct.alter,improve,demolish,or repair any structure y Z y prior to its issuance,also requires the applicant for such permit to file a signed statement x`e that he is licensed pursuant to the provisions of the Contractors license Law(Chapter 9 Sq.Ft.Floor Area Valuation t-$ (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or $500 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). 342321C8 . 00 ❑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 does 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 Contractors u- cense Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a conuwtor(s)licensed pursuant to the Contractors License Law. ❑I 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: ❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen- sation,as provided for by Section 3700 of the Labor Code,for the performance of the irk for which this permit is issued. I 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 WorkCpm ration Insurance carrier and Policy number are: Carried'- GA Policy No.:W.3 063 66�9 CERTIFICATE OF EX PTION 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 the work for which this permit is issued,I shall nes employ any person in any manner so as to become subject to the Workcrs'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 0 forthwith comply with such provisions or this permit shall be deemed revoked. z t-_4 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec.3097,Civ.C.) QLenders Name a Lenders Address U C) I certify that I have read this application and state that the above information is LL E. I---—comply with all city and county ordinances and state laws relating to 0 U building convection,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,judgments,toss and expo rch tp"iy in any way accrue against said City U"Z' in consequence of the grantingroYthis permit.'.,."7 APPLICANT UNI)ERSfANDS AND.WILL COMPLY'WITH ALL NON-POINT Issued b): Date SOURCEyMULATIONS. 1 i" ' . -` "d Re-roofs Signature of Appli Contractor Date fr HAz GUS MATERIALS DISCLOSURE Type of Roof W applicant futon building occupant store or handle hazardous material as dcd 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 If a roof Will the applicant or future building occupant use equipment or devices which .s installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ^� ❑Yes 1 have read the h=rdous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sectio 5,25533 and 25534.1 understand that if the building does oleurently nano it i rcspo rbility to notify the occupant of the qlg mh teh must prior ssm f reatc of occupancy. Signature of Applicant Date All roof coverings to be Class'V'or better Owner ory rized agent Dare (j� � �< <� CITY OF CUPERTINO REPIPE/SEWEIUMAIN SERVICE CUPEt�TINO PERMIT APPLICATION FORM p� Date: APN # L( cD Building Address: Ion , Q G Owner's ame: Phone#: y0 8 - Z53 '21 1 4. CY1GZ� Contractor: Phone#: �fp P— Z S� 6 6 8 Fax#: Contact: Phone#: SUS-3C/ ���.'��" Fax #: Contractor License#: C,a y v 5 Cupertino Business License#: Job Description: Residential ET— Commercial ❑ Valuation: Project Size: Express Standard LargeEl Major 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. Green Building Points: Quantity Fee ID Fee Description Fee Permit Type Group 1PCSEWER Commercial building P 1CPSS sewer/sanitary Newer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1PGASCOM Commercial Gas Piping System P 1-4 Outlets =IBCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICOM Seismic Commercial P Revised 01/07/09 CITY OF C UPERTINO .. REPIPE/SEWERT AIN SERVICE CUPEI�TINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1BCBSC Cal Bldg Standard Commission B ALL PERMIT C Fee TYPES 1BSEISMICR Seismic Residential P 1PRSEWER Residential building P 1RPSS sewer/sanitary sewer 1PRREPIPE Residential re-pipe per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1RPWS 1PPRSEWG Private Sewage D-sposal System P 1 PCESS Cesspool P 1BPWATER Install/alter Water Pipe P 1BPFIXTURE Plumbing Fixture P 1PGASRES Residential Gas P.ping System P 1-4 Outlets 1BPGAS Gas Piping System 5+ Outlets P 1PPERMITFEE Plumbing Permit:-ee Issuance P 1 PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/gas Insp. P 1TRAVDOC Travel & Documentation Fee B 1 BUSLIC Business License B M.In-door Air Quality and Finishes 1.Use towwvoC Paiiart 1 IAQ/Health pts y=yes 0 2.Use Low VOC,Water-Based Wood Finishes 24 IAQ/Health pts y=yes 0 3.Use LowMo VOC Ad MOVes IAQ/Health pts y=yes 0 4.Use Salvaged Materials for Interior Finishes Resource pts y=yes 0 5.Use Engineered Sheet Goods with no added Urea Formaldehyde E IAQ/Health pts y=yes 0 6.Use Exterior Grade Plywood for Interior Uses IAQ/Health pts y=yes 0 7.Seal 4 ExpOed P. ,1laboard or WF IAQ/Health, pts y=yes 0 8.Use FSC Certified Materials for Interior Finish 4Resource 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 1 0 ■ 1 1 1 N.Flooring 1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0 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 yges 0 . 1 1 1 Total Points Available: 401 130 57 Total Points Project Received: 1 01 01 0 G:data/progs/gree nbuiidngguidelinestremodelers/greenpointsfina12.12.04protected.xis Community Development 10300 Torre Avenue '. Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 CUPEkTINO ' Building Department JOB ADDRESS: PERMIT # 0 O 4q,-2— © ss 0OS'r� l� W ONER'S NAME: l�-��2_i�= PHONE # GENERAL CONTRACTOR: FAX # I am not using any subcontractors: " Date Please check applicable subcontractors and co m Mete 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