09060100 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �' Tf " 'C3 �' � *
BUILDING ADDRESS: PERMIT NO.
21611 COLUMBUS AVE PREMIER L
OWNER'S NAME: INC PERMIT ISSUE DATE
A CONTROL NO.
(408) 903-8184
ABUILDING PERMIT INFO
RCHITECT/ENGiNEER:
BLDG ELECT PLUMB MECH
u O p LICENSED CONTRACTOR'S DECLARATION Job Description
O
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of the Business and Pro c Codc,and my license is
=y in full force and eff ?, Com- C COPPER REPIPE FM HOUSE. SHUT OFF THRUOUT HOUSE,
nv�Z License CI Lic.N
i~- Date Contractor NEW
ARCH CTS DEC
I understand my plans shall be use ublic records 40 GAL WATR HEATER
3WQ0.
U.yLicensed Professional
y, OWNER-BUILDER DECLARATION
j�z I hereby affirm that I am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
K,$f which requires a permit to construct,alter,improve,demolish,or repair any structure
y Z prior to its issuance,also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
yt-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 719 6
y .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 70315 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). 35618011 . 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 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,rhe 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 Cade:)The Contractor's Li-
cenm Law does 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.
❑1 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:
have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
-ron,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 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 surance carrier and Policy her are:
Gtrier Policy No:
CERTIFICATE OF EXEMPI70N FROM WORKERS'
COMPENSATION INSURANCE
(This section need Trot be completed if the permit is for one hundred dollars($100)
or less)
I certify that in lbc 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 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z 2 CONSTRUCTION LENDING AGENCY
I hereby affirm that Dere is a construction lending agency for the performance of
tx the work for which this permit is issued(See.3097,Civ.C.)
WG1.A Lender's Name
]z Lendees Address
U 0 1 certify that 1 have read this application and state that the above information is
LL 0- toren.I agree to comply with all city and county ordinances and state laws relating to
0 building construction.and hereby autharim representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
►�-t liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. y
r"r APPLICANT UNDERSTANDS AND WILL COMPLY WITH A ON-POINT Issued by: Date �j--
SOURCE R ULATION .
"/Re-roofs
Sigrbffillftndkior Date
HAZARDOUS MATERIALS DISCLOSURE Type of Loof
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.
C]Yes -,
// If a roof s installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
.,riot?
❑Yes
I have read 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,that it is my responsibility tono. the occupant of the
requiremcats ch must met artoisstr ora PAY• Signature of Applicant Date
All roof coverings to be Class'``or better
r or authomed agent ate
CITY OF CUPERTINO
SM
REPIPE/SEWI;R/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN# A 5-6/ O'� 1)1
2 Date:
Building Address:
v
Owner's Name: Phone#:
6 ; i.� '
Contractor: Phone 3
(/( Fax #:-'1z2,t5) V-S;
ontact: Phone#: �,,:�� �S
_L�2 Fax #:
Contractor License#:
Cupertino Business License#:
Job Description:
L-/ 0
Residential Commercial ❑
Valuatio
I,-
Project Siz : Express Stand 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& the sheet index.
Green Building Points:
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
1BPREPIPE Commercial re-pipe per fixture P 1CPRP
1PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BCBSC Cal Bldg Stanc.ards Commission B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 01/07/09
CITY OF C'UPERTINO
REPIPE/SEWERIMAIN SERVICE
CUPEIZTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1BCBSC Cal Bldg Standaks Commission B ALL PERMIT
Fee TYPES
1BSEISMICR Seismic Residential P
1PRSEWER Residential building P 1RPSS
sewer/sanitary sever
1PRREPIPE Residential re-pip,:per fixture P 1RPRP
l/ 1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1PCESS Cesspool P
/ 1 BPWATER Install/alter Water Pipe P
1 BPFIXTURE Plumbing Fixture P
1 PGASRES Residential Gas P,ping System P
1-4 Outlets
1 BPGAS Gas Piping System 5+ Outlets P
1 PPERMITFEE Plumbing Permit F ee Issuance P
1PLMBLNCK Plumbing Plan C1,eck P
1PLMBINSP Other Plumbing/gas Insp. P
i 1TRAVDOC Travel & Documentation Fee B
1BUSLIC Business License B
M.Indoor Air Ouality and Finishes
1.l*IAV*D-VOC Pmt 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 VOOAdl%Oves 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
0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes
7..5e I Il alE dF ei�atd. AW 41AQ/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 1 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 8 Resource pts y--yes 0
2.Use Rapidly Renewable Flooring Ma#erials 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 D
1 1 1
Total Points Available: 1 1401 1301 57
Total Points Project Received: 116— -01 01 0
prog 6 nbihf9iriggu'ideli modelers/greenpointsfina12.12.D4protected.xls
Community Development
x `
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
"WEkTINO
Buildin De artment
JOB ADDRESS: PERMIT #
a64 oo
OWNER'S NAME: -% PHONE #
GENERAL CONTRACTOR: FAX#
I am not using any subcontractors:
Signature ate
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
Owner/Contractor Signature Date