Loading...
09050018 CITY OF CUPERTINO BUILDING DIVISION PERMIT ANIl ' PERMIT NO. BUILDING ADDRESS: 18771 TILSON AVE PRO R00`CER PERMIT ISSUE DATE OWNER'S NAME: -- �I�,PA'I'R I r H A CONTROL NO. "SONE: (510) 67 )-1115 BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH v p p 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 Professions Code,and my license is REPAIR 3 EWR LAT ERL DO TRNC H LESS AND I N S T L CITY H in full force and eft _ ? License CI ss Contractor CLEAN OJT ,ARCHITECTS DECLARATION I understand my plans shall be used as public records �yU `�I— Licensed Profcsxional OWNER-BUILDER DECLARATION `X I hereby alTirrn that 1 am exempt from the Contractor's License law for the p O following mason.(Section 703 1.5,Business and Professions Code:Any city or county _ K.V which requires a permit to construct,alter,improve,demolish,or repair any structure prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Y h$ (commencing with Section 7000)of Division 3 of the Business and Professiona Code)or $4200 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(5500). 37517033 . 00 ❑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 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.). ❑I,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- ccnse Law docs not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a conuactor(s)licensed pursuant to the Contractor's License Law. ❑I am exempt under Sea 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-insum for Worker's Compen- ,etion,as provided for by Section 3700 of the Labor Code,for the performance of the work 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 work for%hIyb this rmit is issued. My Worker's Com enation Insurance carrier and Policy no are: y Carrier. © cy No.: <� ERTIFICATE OF ON FRO RK S. COMPENSATION INSURANCE ('Phis 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 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 provision of the Labor Code,you must Oforthwith comply with such provision or this permit shall be deemed revoked. ,Z r'" CONSTRUCTION LENDING AGENCY [�►N. I hereby affirm that there is a convection lending agency for the performance of a> the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lendces Name Z Lender's Address U 0 1 certify that 1 have mad this application and state that the above information is 4.F correct.1 agree to comply with all city and county ordinances and state laws mlating to 0 V building convection,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes 1/7 a (We)agree to save.indemnify and keep harmless Use City of Cupertino against to liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. Date �+ APPLICANT UNDERSTAN S AND WILL COMPLY WITH ALL NON-POINT Issued by: SOMUG U TI / e :0 �� �✓! J �q Re-roofs — Vignaturo of Applicant/Contractor Dale Type of Loof 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)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes Will a roof s installed without first obtaining an inspection,I agree to remove ll the applicant or future building occupant use equipment or devices which nit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? / ❑yos u 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Section 25505.25533 and 25534.1 understand that if the building does not currently have a tenant,that it is my responsibility to notify the occupant of the require hick tut etpriart n facer,irreateofacupartey. Signature of Applicant Date �,�/ "��� All roof coverings to be Class"{`'or better ner or authorized gent CITY OF CUPERTINO REPIPE/SEWEI?./MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM ., APN# J� ! _7 o 3- d� Date: Building Address: E3 L 7i2 " (, Own is Phone#: Name: o � o Phone : S— Con ctor: Fax#: Contact* Phone#: kS�QU6 '7 Fax#: �/ Contractor License#: Cupertino Business License#: Job Description: _r�,r� d A'y C- i C� tit S S' i CL <::V© Residential Commercial ❑ Valuation: 0 Project Size: Express Standard —Large [I 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 bi:.ilding P 1CPSS sewer/sanitary sewer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1PGASCOM Commercial Gis Piping System P 1-4 Outlets 1BCBSC Cal Bldg Stanc.ards Commission B ALL PERMIT Fee TYPES IBSEISMICOM Seismic Commercial P Revised 01/07/09 CITY OF CUPERTINO REPIPE/SEWEPJMAIN SERVICE CUPEIZTINO FEE SCEIEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES / 1BSEISMICR Seismic Residential P 1PRSEWER Residential building P 1RPSS sewer/sanitary server 1PRREPIPE Residential re-pipe per fixture P IRPRP 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 1PGASRES Residential Gas Piping System P 1-4 Outlets 1 BPGAS Gas Piping System 5+ Outlets P 1 PPERMITFEE Plumbing Permit Fee Issuance P 1 PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/ -As Insp. P 1TRAVDOC Travel & Docum(;ntation Fee B 1 BUSLIC Business License B M.Indoor Air ualrty an Finishes 1.Use Low No-VOC Paint I IAQ/Health pts y=yes 0 2.Use Low VOC,Water-Based Wood Finishes ?IAQ/Health pts y=yes 7 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 31AQ/Health pts y=yes 0 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0 7.Seal aQ;CxMWPa ieboard,or ACDF 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 . 1 1 1 N.Flooring 1.Select FSC Certified Wood Flooring E Resource pts y=yes 0 2.Use Rapidly Renewable Flooring Materials 2 Resource pts y=yes 0 3.Use Recycled Content Ceramic Tiles 1 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 . 1 1 1 ol Total Points Available: 1401 1301 57 Total Points Project Received: 01 0 0 i G:d rogs/gm nbuildngguidelines/remodelers/greenpointsfinal2.12.04protected.xis Community Development 10300 Torre Avenue - `' Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 *TPEkTINO Building Department JOB ADDRESS: PERMIT # OWNER'S NAME: c, - v C PHONE # n ,2 6 GENERAL CONTRACTOR: _ © c FAX # I am not using any subcontractors: K 5— Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSI:vESS 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