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BUILDING DIVISION PERMIT
BUILDING ADDRESS:
OWNER'S NAME:
ARCHITECT/ENGINEER:
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. apd my license is
in full force and effecK1 � dl
License 1 s l..i LCJ Lic• N
Date Contrxtor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors 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 repair any structure
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
(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).
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
and Professions Code: The Commetoes 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. IL
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.).
O 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors 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.
EJ1 am exempt under Sec. B & P C for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION
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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 Workers Compen-
sn, as provided for by Section 3700 of the Labor Code, for the performance of the
..ork for which this permit is issued.
XI have and will maintain Worker's Compensation Insurance, as required by Section
of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
f
4- 7_
Carrier. `l Fey K No.: 5-
CERTIFICATE p EXEMPTION FROM RKERS'
COMPENSATION INSURANCE
(Chis 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. 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 provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lenders Address
I certify that I have read this application and state that to above information is
cortccL l agree to comply with all city and county ordinances and stare laws relating to
building construction. and hereby authorize representatives of this city to enter upon the
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 accrue against said City
in consequence of the granting of this it.
APPLI ANT UND STANDS A WILL OMPLY WITH AL NO POINT
SOU
nt"M
Sig turcApplirant/Conttactor are
HAZARDO ATERIALS 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)?
❑ yes foto �o
Will the applicant or building occupant use equipment or devices which
'it hazardous air contaminants as defined by the Bay Area Air Quality Management
ries?
Ayes �I u
1 have read the hazard(wss 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 hawAa. `tenant at it is my responsibility to notify the occupant of the
requirements ty� i(p ro" nje Aor to issuance of a C�crt'Ite�0/- 'A y.
Owner or
Date
293-7
Job Description
INSTL FURNC, A/C AND DUCTWORK
Sq. Ft. Floor Area Valuation
816000
APN Number Occupancy Type
375050C2.00
Issued b):
Re -roofs
Type of Roof
Required Inspections
wri
Date —�
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.
Signaturc of Applicant Date
All roof coverings to be Class 'W' or better
PERMIT NO.
ATR
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PERMIT ISSUE DATE
S A e 8 9
CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT
PLUMB
Job Description
INSTL FURNC, A/C AND DUCTWORK
Sq. Ft. Floor Area Valuation
816000
APN Number Occupancy Type
375050C2.00
Issued b):
Re -roofs
Type of Roof
Required Inspections
wri
Date —�
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.
Signaturc of Applicant Date
All roof coverings to be Class 'W' or better
oqo(o oo3�7
CITY OF CUPERTINO
FURNACEAC
CUPEI�TINO PERMIT APPLICATION FORM
APN # � � � � °
Date:
Building Address:
Owner's Name:
Phone #:
Contractor: 91 k �
/
Phone #: f1(B�" �—7 k?
Fax #:
Contractor License #: 7 I
Cupertino Business License #:
Contact:
Phone #: (14 ?'- 2,q3-713/
/AIM W/^-
Fax #:
Building Permit Info:
Electe------ Plumb U/
Mech E�--�
Residential X
Commercial ❑
Job Description:
'AWAZ/
For Residential Installations:
Attic ❑ I" floor []
2°d floor ❑
Adhere to minimum setback requirement
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installatio i
❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction (Usage Class):
11
Strapped On Platform ❑ Bonded
New Location Replacement
Project Size: Express Standard ❑ Large ❑
Major ❑
Valuation: 11 I�
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. (51 --
Revised U1/U//Uy
CITY OF C.UPERTINO
FURNACEAC
CUPEk INO FEE SCHEDULE
Quantity
Fee ID
Fee Description
Fee
Permit Type
Group
FURNACE
FURN/AC
1MCRAA
Commercial-Repair/Alteration/Add to
M
ea heating appli.ince,refrigeration unit,
cooling unit, abs:)rption unit,or ea
heating,cooling, absorption or
evaporative coo ing system,incl
installation of controls regulated by this
code.
1 MCREPALT
Commercial for the repair of alt/add to
M
ea heating applimce,refrigeration
unit,cooling uni,:,VAV boxes,
absorption unit or ea heathing, cooling
absorption,or evaporative cooling sys,
incl install of controls regulated by
this code.
1 MCSUSHTR
Commercial Ins :all/Relocate ea
M
suspended heater,recessed wall htr, or
floor mounted unit heater.
1PGASCOM
Commerical for ea gas piping System
P
1-4 outlets
1 BPGAS
For each gas pir ing system of 5 or
P
more per outlet.
1MCAPPVNT
Commercial for the install/relocate/ or
M
replacement of ca appliance vent
installed & not incl in an appliance
permit.
1BCBSC
Cal Bldg Standards Commission Fee
B
ALL PERMIT
TYPES
1BSEISMICO
Commercial Seismic
B
1 MRRAA
Residential Rep iir/Alteration/Add to
M
ea heating applimce,refrigeration unit,
cooling unit, ab s:)rption unit,or ea
/
heating,cooling, absorption or
evaporative coo .ing system,incl
installation of controls regulated by
this code.
1MRSUSHTR
Residential Install/Relocate ea
M
suspended heater,recessed wall htr, or
floor mounted unit heater.
CITY OF
CUPEkTINO
CITY OF CUPERTINO
FURNACE/AC
FEE SCHEDULE
Quantity
Fee ID
Fee Description
Fee
Group
Permit Type
AIR
CONDITIONING
FURN/AC
1BCAIRHAN
Commercial A/C Units <= IOk CFM
B
1MCRAA
Commercial Mech Repair/alt/add
M
1BCBSC
Cal Bldg Standards Commission Fee
B
ALL PERMIT
TYPES
1BSEISMICO
Seismic Commer3ial
B
1PGASCOM
Commerical for ea gas piping System
1-4 outlets
P
1 PGASRES
Residential for eE gas piping system
of 1-4 Outlets
P
1BPGAS
For each gas piping system of 5 or
more per outlet. Comm/Resid
P
1 BREMAIRHAN
Residential A/C units <= l 0k CFM
B
1MRRAA
Residential Mech. Repair/alt/add
M
I
1BCBSC
Cal Bldg Standards Commission Fee
B
ALL PERMIT
TYPES
1 BSEISMICR
Seismic Resident ial
B
1 EPERMITFEE
Electric Permit
E
1 MPERMITFEE
Mechanical Permit
M
1PPERMITFEE
Plumbing Pen -nil
P
1TRAVDOC
Travel Documentation
B
1BUSLIC
Business License;
B
1. Use toalo-VOC R&A
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
4 Resource pts
y=yes
Formaldehyde
61AQ/Health pts
y=yes
6. Use Exterior Grade Plywood for Interior Uses
1 IAQ/Health pts
y=yes
7. SealalExpowdPaWeboaxila MDF
41AQ/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
N. Flooring
1. Select FSC Certified Wood Flooring
8 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 1401 130 57
Total Points Project Received:1 1 01 01 0
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G:data/progs/gre enbuildingguidelines/remodelers/greenpointsfinal2.12.o4protected.xls
CM OF
flffkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
_ 47 Building Department
JOB ADDRESS:
Z
PERMIT #
01`l 6�Os"�
OWNER'S NAME: <m LV¢}- D
PHONE # �- ? 6 7
GENERAL CONTRACTOR: &
FAX #
I am not using any subcontractors:
Signature ate
Please check applicable subcontractors idd complete the following information:
Owner/ Contractor Signature
Date
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