09050083 CI'T'Y OF CUPERTINO
BUILDING DIVISION PERMIT *
BUILDING ADDRESS: PERMIT NO.
21088 RED FIR CT GR AT AMERICAN PLITMBING C-0 pqo5nngi
OWNER'S NAME: INC PERMTf ISSUE DATE
'.10—dy
P E) B 1H 26942 S CONTROL NO.
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
RE-PIPE FROM GALVI TO COPPER O O L__J D
uad 0LICENSED CONTRACTOR'S DECLARATION
0 & WATER HEATER, Job Description
m C 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
Y(�� with Section 7000)of Division 3 of the Business and Professions Code.and my license is
y in full force and eft .2(o
Z License Class J i
t:
Q Dam r Contractor
RCHr1ECPS DECLARATION
I l understand my plans shall be used as public records
D,U
`O Licensed Professional
H OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
m O following reason.(Section 7031.5,Business and Professions Code:Any city or county
e$066 which requires a permit to construct,alter,improve,demolish,or repair any structure
y Z y prior In its issuance,also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9 Sq.Ft.Floor Area Valuation
_
X
t—a (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y .. 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(SM.
❑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 Contractor's License Law dors not apply m 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 ate 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
constmict the project(Sec.7044,Business and Professions Cade:)The Contractoes 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 Sec. B&P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I 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-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
Q[I have and will maintain Workers Compensation Insurance,as required by Section
700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workke'r, Compensation Insurance carrier and Policy number
Cartier Worker,
&_,Y Policy No.: -Ej
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section creed 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,1 shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Dam
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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
(,—ei►�—� I hereby affirm that there is a construction lending agency for the performance of
(Y. the work for which this permit is issued(Sec.3097,Civ.C.)
W Q L.endces Name
Lenders Address
IJ 0 I certify that 1 have read this application and state that the above information is
LL"" corroct I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorise representatives of this city to enter upon the
>4 Wabove-mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Ia.
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 AN WILL COMPLY WITH ALL NO Issued by: Date
SOURCE REGU ONS,
c Re-roofs
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle harardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,section 25532(x)? All roof;shall be inspected prior to any roofing material being installed.
❑Yes WNo
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
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new:naterials for inspection.
District?
❑Yes �No
1 have mad 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 currently have a tenant,th�irh is m responsibility m notify the occupant of the
require hidfi must be met m' ante of a Certifcate of oc an . Signature of Appl ieant Date
Owner or authorized agent
Dam All roof coverings to be Class'`'or better
CITY OF CUPERTINO
tt a REPIPE/SEWF4R/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
Cqt6` 06B
APN# Date:�6 �« �a . U/ l S D
Building Address: J
1 C t;8 ( �'
Owner's Name: Phone#:
JU cG-,er o 9 • 395
Co�actor: / Phone#
fs vt,�y 4 4el to Fax #: �y0�, 2 7
Contact: Phone#:
i l�0'►'Ne 1_ Fax #: C716?)
Contractor License#: SQ 16 6 5-
Cupertino Business License#:
Job Description:
V,VT 7,of C6 tel 4yn 6n(VI fo (o� Y '�
Residential Commercial ❑
Valuation:
Project Size: Express Standard Large Major
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set 8: the sheet index.
Green Building Points:
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCSEWER Commercial b-iilding P 1CPSS
sewer/sanitary sewer
1BPREPIPE Commercial rc-pipe per fixture P 1CPRP
1 PGASCOM Commercial C as Piping System P
1-4 Outlets
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 01/07/09
CITY OF CUPERTINO
REPIPE/SEWEIUMAIN SERVICE
Of
CUPERTINO FEE SCHEDULE
Quantity Fee ID Fee Descriptic,n Fee s Permit Type
Group
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICR Seismic Residential P
1PRSEWER Residential building P 1RPSS
sewer/sanitary se,ver
/ 1PRREPIPE Residential re-pile per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1 PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
1 BPFIXTURE Plumbing Fixture P
1 PGASRES Residential Gas Piping System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
/ 1 PPERMITFEE Plumbing Permit Fee Issuance P
1PLMBLNCK Plumbing Plan Check P
1PLMBINSP Other Plumbing/gas Insp. P
1TRAVDOC Travel & Documentation Fee B
1BUSLIC Business License B
M.Indoor Air Ouallty and Finishes
1.Use 1 owWVOC Paid 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3.Use Lowft 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 61AQ/Health pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7.Seal all iE.*osedP*;Iab=dsorMAF 4 IAQ/Health. 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=yes 0
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 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 4 Resource pts y=yes 0
Total Points Available: 1401 1301 57
Total Points Project Received:-/ IT d t7 01 01 0
G:data/progs/g,eenbuildingguidelinestremodelers/greenpointsfinal2.12.D4protected.xls