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CITY OF CUPERTIi
BUILDING DIVISION
BUILDING ADDRESS:
11256 VALO:
OWNER'S NAME.
.'HITEC'r/ENGINEER:
PERMIT
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and �2
License Class 0� (- Lic. x 3
Date _ Con
AR HrrECTS DEC TION
I understated my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct. alter. improve, demolish, or mpair any structure
prior to its issuance, also requires the applicant for such permit to fele a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
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
not more than five hundred dollars (5500).
❑ 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
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.).
❑ 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 U.
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 Sea B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARAMON
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I 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
-k for which this permit is issued.
,dahave and will maintain Worker's Compensation Insurance, as required by Section
700 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:
Carrier. i c-� Policy No.: G7,CV eO 6Gs7nZ
CT"FICATE 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. 1 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
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby strum 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 Q Lender's Name
Z Lender's Address
V C) I certify that I have read this application and state that the above information is
correct- I agree to comply with all city and county ordinances and state laws relating to
0 V building construction, and hereby authorize representatives of this city to enter upon the
a above-mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way scenic against said City
V Z in consequence of the granting of this permit.
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
S REGUL MONS.
Signature of Appiicant/Contractor VDare
HAZARDOUS MATERIALS DISCLOSURE
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)? ppp
1:1 Y- Q O 0
Will the applicant or(futum building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Amo Air Quality Management
District?
❑ Yes u
I have mad the matcrisis requirements underChaptcr6.95 of the Califor-
nia Health & Safety Code, Soctons 25505, 25533 and 25534.1 understand tut iC the building
does not cunent ave a tenant, that it is my responsibility to notify the occupant of the
requirementsmust be me prior;"tyn ce of a Ccnificats of Occupancy.
.
RMV/RFLC AC UNIT
Issued by
Re -roofs
Type of Roof
Ft.
APN
PERMIT NO.
ngocionss
PERMIT ISSUE DATE
SA CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
D O D D
Job Description
Required Inspections
Valuation
Occupancy
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
S —,/ z - 0001s
Signature of Applicant Date
Owner or authorized agent Date
All roof coverings to be Class 'W' or better
CITY OF
CUPEkTINO
CITY OF CUPERTINO
FURNACE/AC
PERMIT APPLICATION FORM
0 � D -', �-- C) (� - --- ---� �
APN # 0 (P( Ci 3 ( ; C_�
Date: Z Uv y
Building Address:
C d
Owner's Name:
Phone #:
Contractor:` .v.� ct �c,- s =
Phone #:
Fax M
Contractor License M -3 ?Cf �
Cupertino Business License M
Contact:
<eG Jam/
Phone#:
7o7
Fax #:
Building Permit Info:
Elect ❑ Plumb [/ Mech
ResidentialU Commercial ❑
Job Description, -V _ A C
U
For Residential Installations:
Attic ❑ 15t floor [] 2nd floor ❑
Adhere to minimum setback requirement
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 PlatformEl Bonded New Location Replacement
Project Size: Express ❑ Standar Large 1:] Major ❑
Valuation: iqo
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
CUPEkTINO
CITY OF CUPERTINO
FURI�IACE/AC
FEE SCHEDULE
Quantity
Fee ID
Fee Description
Fee
Group
Permit Type
1 MRAPPVNT
Residential for the install/relocate/ or
replacement u7ea appliance vent
install & not incl in an appl permit.
M
FURNACE
FURN/AC
1 PGASRES
Residential foi ea gas piping system of
1-4 Outlets
P
1 BPGAS
For each gas piping system of 5 or
more per outlet.
P
1BCBSC
Cal Bldg Standards Commission Fee
B
ALL PERMIT
TYPES
1BSEISMICR
Residential Se.smic
B
1MECPLNCK
Mechanical Pl,in Check
M
1MFR=<100
Furnace Syst <=100k BTU install or
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance up to and
include 100,000 Btu/h
M
1 MFRN> 100
Furnace Syst > l 00k BTU install or
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance over
100,000 Btu/h
M
1 EPERMITFEE
Electric Permit Fee
E
1MPERMITFEE
Mechanical Pe -mit Fee
M
1PPERMITFEE
Plumbing Perndt
P
1 TRAVDOC
Travel Documentation
B
1BUSLIC
Business License
B
CITY OF C UPERTINO
X.
�_,,,FURNYXE/AC
.
CUPEkTINO FEE SCHEDULE
Quantity
Fee ID
Fee Description
Fee
Group
Permit Type
AIR
CONDITIONING
FURN/AC
1 BCAIRHAN
Commercial A/C Units <= l Ok CFM
B
1MCRAA
Commercial Mech Repair/alt/add
M
1BCBSC
Cal Bldg Standar is Commission Fee
B
ALL PERMIT
TYPES
1BSEISMICO
Seismic Commer-.ial
B
1PGASCOM
Commerical for ca gas piping System
1-4 outlets
P
1 PGASRES
Residential for ea gas piping system
of 1-4 Outlets
P
1BPGAS
For each gas piping system of 5 or
more per outlet. C;omm/Resid
P
1197
1BREMAIRHAN
Residential A/C units <= IOk CFM
B
/
1MRRAA
Residential Mech Repair/alt/add
M
1 BCBSC
Cal Bldg Standar is Commission Fee
B
ALL PERMIT
TYPES
1BSEISMICR
Seismic Residential
B
1 EPERMITFEE
Electric Permit
E
1MPERMITFEE
Mechanical Permit
M
1 PPERMITFEE
Plumbing Permit
P
1TRAVDOC
Travel Documentation
B
1BUSLIC
Business License
B
Plan Review Process Work Book Page -12-Revised 3/25/08
Green Building Plan Check
Index of Green Building Points/Categories
A. Category
Example of an Index or Table of Green
Plan Sheet or Page
Points
Building Points Categories that mus: be
shown and referenced on the Projekt
Plans See below
�t
P11 111111:11:12liq
NOR
B. Site
9. Install H.E. Irrigation, (details/spe(;)"
L-1
2 points
11. Permeable Paving, Note
L-1
2 points
C. Foundation
1. Use 15 % Flyash Concrete, (note;
S-1
5 points
D. Structural
3. Uses Wood I-Joist, (See Spec.)
S-2
2 points
5. Use Truss with heels, (detail)
S-2
2 points
6. B. OSB Sheathing, detail
S-2
2 points
E. Ext. Finish
1. Composite Decking, (Note/Spec.)
A-3
2 points
4. B. Fiber Cement Siding, Note/S ec.
A-4
2 points
F. Plumbing
1. Insulate all H.W. pipes, (Note/Spec.)
P-1
2 points
5. Tankless W.H., (Note/Spec.)
A-2
2 points
11. A 2500 Gal. Tank, Note/S ec
L-1
10 points
G. Electrical
4. E. Ceiling Fans, (Note/Spec.)
A-3
4 points
H. Appliances
1. Energy Star Dishwasher, (Note/Spec.)
A-3
1 point
3. Energy Star Refrigerator, (Note/Spec.
A-3
1 oint
P. Other
1. List Green Features on Plans
A-1
1 point
TOTAL PC INTS
40 points
Plan Review Process Work Book Page -12-Revised 3/25/08
1. ins1a11
a. 1 Energy pt
b.1Aw-still! 2 Energy pts
C. Low.ty 2 Energy Pts
2. Install Low Heat Transmission Glazing 1 Energy pt
J. Heating Ventilation and Air Conditioning
1. Use 0M MaWc to A Duct !pints
2. Install Ductwork within Conditioned Space
3. Vent Range Hood to the Outside
4. Clean all Ducts Before Occupancy
5. Install Solar Attic Fan
6. Install Attic Ventilation Systems
7. Install Whole House Fan
8. Install Sealed Combustion Units
a. Furnaces
b. Water Heaters
9. Replace Wall -Mounted Electric and Gas Heaters with
Through -the -Wall Heat Pumps
10. Install 13 SEER/11 EER or higher AC with a TXV
11. Install AC with Non -HCFC Refrigerants
12. Install 90% Annual Fuel Utilization Efficiency (AFUE) Furnace
13. Retrofit Wood Burning Fireplaces
a. Install EPA certified wood stovWinserts
b. Install/Replace Dampers
c. Install Airtight Doors
14. Install Zoned, Hydronic Radiant Heating
15. Install High Efficiency Filter
16. Install Heat Recovery Ventilation Unit (HRV)
17. Install Separate Garage Exhaust Fan
IG Renewable Energy and Roofing
1. Pre -Plumb for Solar Water Heating
2. Install Solar Water Heating System
3. Pre -Wire for Future Photovoltaic (PV) Installation
4. Install Photovoltaic (PV) System
(1.2 kw = 6 points, 2.4 kw =12 points, 3.6 kw =18 points)
6. Select Safe and Durable Roofing Materials
7. Install Radiant Barrier
L. Natural Heating and Cooling
1. Incorporate Passive Solar Heating
2. Install Overhangs or Awnings over South Facing Windows
3. Plant Deciduous Trees on the West and South Sides
2 Energy pts
y=yes
3 Energy pts
y=yes
1 IAQ/Health pt
y=yes
21AQ/Health pts
y=yes
2 Energy pts
y=yes
1 Energy pt
y=yes
4 Energy pts
y=yes
31AQ/Health pts
31AQ/Health pts
3 Energy pts y=yes
3 Energy pts y=yes �� 3
Resource pts y=yes X c �0 Z
2 Energy pts y=yes
1 IAQ/Health pt
y=yes
1 Energy pt
y=yes
1 Energy pt
y=yes
3 Energy pts
y=yes
41AQ/Health pts
y=yes
3 IAQ/Health pts
y=yes
31AQ/Health pts
y=yes
4 Energy pts y=yes
1) Energy pts y=yes
4 Energy pts y=yes
Up to 18 Energy pts
1 Resource pt y=yes
3 Energy pts y=yes
5 Energy ptsy=yes 0
3 Energy pts . y=yes 0
3 Energy pts y=yes 1 0
sn{
r
I
1. Use Low/No-VOC Paint 1 IAQ/Health pts y=yes
2. Use Low VOC, Water -Based Wood Finishes 2 IAQ/Health pts y=yes
3. Use Low/No VOC Adhesives 3 IAQ/Health pts y --yes
4. Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes
5. Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes
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
8. Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes
9. Use Finger -Jointed or Recycled -Content Trim 1 Resource pts y=yes
10. Install Whole House Vacuum System 3 IAQ/Health pts y=yes
0
0
0
1. Select FSC Certified Wood Flooring
0
0
0
0
0
0
y=yes
2. Use Rapidly Renewable Flooring Materials
4 Resource pts
y=yes
3. Use Recycled Content Ceramic Tiles
4 Resource pts
y=yes
4. Install Natural Linoleum in Place of Vinyl
5 IAQ/Health pts
y --yes
5. Use Exposed Concrete as Finished Floor
0
N. Flooring
1. Select FSC Certified Wood Flooring
B Resource pts
y=yes
2. Use Rapidly Renewable Flooring Materials
4 Resource pts
y=yes
3. Use Recycled Content Ceramic Tiles
4 Resource pts
y=yes
4. Install Natural Linoleum in Place of Vinyl
5 IAQ/Health pts
y --yes
5. Use Exposed Concrete as Finished Floor
4 Resource pts
y=yes
6. Install Recycled Content Carpet with Low VOCs
4 Resource pts
y=yes
Total Points Available:1 1 1401 1301 57
Total Points Project Received:13 Q -S-01 �1
�e
G:data/progs/gn enbuilcgngguidelines/remodelers/greenpoin fina1212.04protected.xls
Community Development
10300 Torre Avenue
Cupertino CA 95014
FA. Telephone (408) 777-3228
Fax (408) 777-3333
CITY OF
CUPEkTINO
Buildi�l De =arftiaent
JOB ADDRESS: P#�-�-r
i
of t� PHONE # ' `l..
OWN& 'S NAME: S O /�
GENERAL CONTRACTOj V= FAX #
R:
I am not using any subcontractors:
Sign tune Date
Please check
a licatne suDC0nUdLLu1t1 LULU %-Ulla ,.LV- u- a------- --_ ___
SUBCONTRACTOR BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
x
Glass / Glazing
Heating
6 00
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
�- -!t - 2c:P) 9-
Owner/Contractor gna Date