09050167 CITY OF CUPERTINO
BUILDING DIVISION PERMIT 't_!
t%pERMrr
.
BUILDING ADDRESS: 0167
7750 OROGRANDE PL JONES MP
SUE DATE
OWNER'S NAME:
2 0 11
MONICA PROCTOR
SAN ARY NO. CONTROL NO.
")NE:
4083777- 12
BUILDING PERMIT INFO
ARCHIIECTIENGINEER: BLDG ELECTPLUMB MECH
E 0
1400
LICENSED CONTRACTOR'S DECLARATION Job Description
w p I hereby affirm that I am licensed under provisions of Chapter 9(commencing
w with Section 7000)of Division 3 of the Business and Professions Code.and my license is 2 STORY FIREPLACE REPAIR FM ROO F L I NE
y in full force an flee
v�Z License s Contractor
t–o Date
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
�yU
O In Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
i
no following reason.(Section 7031.5,Business and Professions Code:Any city or county
14^Pi which requires a permit to construct,alter,improve,demolish, file
repair any structustatement
Valuation
prior to its issuance.also requires the applicant for such permit to file a signed statement 'j Ft.Floor Area
z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q $3500
YF=- (commencing with Section 7000)of Division 3 of the Business and professions Cade)or
y that he
is, therefrom and the basis for the al►cgcd exemption.Any violation o[ ApN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars(M). L3621802:,) . 00
O 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 Conusctoes 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(Sec.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 contractor(s)licensed pursuant to the Contractor's
License Law' B do P C for this reason
0 I am exempt under Sea
Owner Date
WORKER'S COMPENSATION DECLARATION
y affirm under penalty of perjury one of the following declarations:
have and will maintain a Certificate of Consent to self-insure for Workces Compen-
_awn,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
0 I 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 Worker's Compensation Insurance carrier and Policy 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 IC3L)
I certify that in the performance of the work for which this permit is issued,l shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of Crb
e
Applicant
NOTICE NT:lf,after making th' Certificate of Exemption,you should
become suorkces Compensation provisions of the Labor Code,you must
,Z forthwith uch provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
F~t rte.. I hereby affirm that there is a construction lending agency for the performance of
p;> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
Lender's Address
z
U 0 1 certify that I have read this application and state that the above information is
correct 1 agree to comply with all city and county ordinances and state laws relating to
U building concoction,and hereby authodie representatives of this city to enter upon the
0 above-mentioned property for inspection purposes
W
W (We)a Tee to save,indemnify and keep harmless the City of Cupertino against
C14Liabilities, C.
casts and expenses which may in any way accrue against said City '
V z in co nee C the granting or this permit Date — r� S
►. APPLIC NT NDERSTANDS AND WILL COMPLY WITH L N POINT Issued b):
SOUR ULA
Re-roofs
Si A ican tractor °'� T of Roof
RDOUS MATERIALS DISCLOSURE Type
Will tea 'cantor future building occupant.store or handle hazardous material
as defined by the Cupenino 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.
0Yes ONO 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
t hazardous air contaminants as defined by the Bay Area Air Quality Management all new r-iaterials for inspection.
,vitt?
0 Yes ONO
I ha read the harard,)us materials requirements under Chapter 6.95 of the Califor-
nia Health cty Code,Sections 25505,25533 and 25534.1 untie that if the building
does not tly have tenant.that it is my responsibility to notif the occu ant of the Date
require which at prior to' ofaCcrtif r =�yy Signaturt°of Applicant
�6 All roof coverings to be Class'A.'or better
Owner or orix gc ate
����o � ��
CITY OF C UPERTINO
CITY OF
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # Date:
oaf civ
Building Address: ., '7
Mailing Address (if different from buildin� address):
Owner's Name: > pt Phone#:
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from HOA
Contra
tor: :y� Phone _7 �/. 72t _
l Cl._�--�`�v�? Fax: 7 7 Sl
Contractor License #:
Cupertino Business License #: ✓ c'-��
Contact: ,��' Phone: j1 7
Fax: -7
Residential Commercial ❑
Job Description: LL ✓ �L..��a��C c' , � �4� V6 4
Building Per it Info:
BldgElect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B P (L 3
Valuation: I Square Footage:
Project Size: Express &J---Standard ❑ Large [] Major ❑
Green Building: Please complete relevant portion or 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.builditgref n.or
Revised 02/05/09
t�`f CITY OF CUPERTINO
COPCM E F GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
ACOUSTICAL
REVIEW
IACOUSFDW SFDWL/Duplex New B
IACOUSRESAD SFDWL/:duplex-Addition/Alteration B
1 ACOUSCOM Multi-Fainily/Commercial B
CHIMNEY'S
1 CHIMNEY Chimney B
1 CHIMNEYR Chimney Repair B
FENCES
1FENCE>6FT Non-masonry, over 6 ft in height B
1 FENCEMAS>6 Masonry, over 6 ft in height B
FIREPLACES
1 FIREPLMAS Fireplacc Masonry B
1 FIREPLFAB Fireplacc Pre-Fabricated/Metal B
1 FLAGPOL>20 Flag poll; (over 20 ft in height) B
1 MODUSTRU Modular Structures B
FOUNDATIONS
1 FOUNDREP Foundation Repair B
1PILECAST Pile Fouldation Cast in place concrete B
1 PILEDRIV Pile Foundation Driven (steel, pre- B
stressed concrete)
3 of 5
adCITY OF CUPERTINO
CITY Of GENERAL BUILDING APPLICATION
CUPEI�TINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additional stucco application
1 WINREP Replacem,-nt windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Window-structural shear B
wall/masonry (includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit Fee P
1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard flan Check (when no E/M/P) B
when not over counter) hourly-stand alone
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1 BSEISMICR Seismic Residential B
1 BSEISMICO Seismic Commercial B
1 TRAVDOC Travel & Documentation B
1BUSLIC Business license B
5 of 5
114F UT RL-scurces 1AD'HLafth
M. Enu
Indoor Air Quality and Finishes '
1.Use le*No-VOC Paint I IAQ/Health pts y=yes 0
2,Use Low VOC,Water-Based Wood Finishes ?IAQ/Health pts y=yes 0
3.Use Lov*Wo 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 31AQ/Health pts y=yes 0
7.Seed al Exposed Particleboard or MDF 41AQ/Health. pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 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 1 0
. 1 i 1
N.Flooring
1.Select FSC Certified Wood Flooring E Resource pts y=yes 0
2.Use Rapidly Renewable Flooring Materials z Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles z Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl i IAQ/Health pts y=yes 0
5.Use Exposed Concrete as Finished Floor Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs Resource pts y=yes 0
Total Points Available: 1401 130 57
Total Points Project Received: 0 0 0
-31
GAaWprogs/gret nbuilcOngguidelines/remo enpointsfinal2.12.o4protected.xls
11 Community Development
`" 10300 Torre Avenue
X10,
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPE�TINO
Buildinn De artment
JOB ADDRESS: PERMIT # /'V�
OWNER'S NAME: r �' r PHONE # �U
GENERAL CONTRACTOR: FAX #
514 09
I am not using any subcontractors: �^�� ?—
i;;nature D to
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
r/Contractor Signature Date