09060034 CITY OF CUPERTINO
BUILDING DIVISION PERMITRMI��Y',
PERMIT NO.
'BUILDING ADDRESS:
7551 KIRWIN LN
PERMIT ISSUE DATE
OWNER'S NAME:
SWWAkACONTROL NO.
nH0
(408) 666-5298
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
0 0 o a
u O p LICENSED CONTRACTOR'S DECLARATION Job Description
V C 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z m with Section 7000)of Division 3 of the Business and Professions Code,and my license is
H UPGRD E:SEC VOLTG FM 11,0 TO 220
in full force and effect.
j ? License Class Lte•tf
±Ftp Dam Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
5 U
L C y Licensed Professional
OWNER-BUILDER DECLARATION
2M1 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
y^6.1 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
G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 3q.Ft.Floor Area
X t'• (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 15 0 0
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). 35921001 . 00
0 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(See.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
sate.).
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contras s Li-
cease Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law.
0 1 am exem t�und�err Seecc..� B&P C for this reason
Owns �1L Date!�
WORK ' COMPENSATIO ECLARATION
I hereby affirm un penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self-insure for workers compen-
.on,as provided for by Section 3700 of the Labor Code,for the performance of the
.pork for which this permit is issued.
0 I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workees Compensation Insurance carrier and Policy number are:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
1 certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any mannerspas t� ecome sued to the Workers'Compensation
Laws of California j�aLr-(�� l
Applicant
NOTICE TO APPPUCA ,of eking 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
[[r►�-� I hereby affirm that there is a construction lending agency for the performance of
5 the work for which this permit is issued(Sec.3097,Civ.C.)
W QLender's Name
0 Lender's Address
V C) I certify that I have read this application and state that the above information is
LL" correct.I agree to comply with all city and county ordinances and state laws relating to
0U building construction,and hereby authorize representatives of this city to enter upon the
s
W above-mentioned property for inspection purpose
0-1 CL (We)agree to save,indemnify and keep harmless the City o[Cupertino against
v) liabilities,judgments,costs and expenses which may in any way accrue against said City r(
V Z in consequence of the granting of this permit. Date �J
t-- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUR TIO /CJ/O
- 1 Re-roofs
Signature of Apphcwu/Contrac � Dam Type of Roof
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
Cotte,Section 25532(a)? ONO All roofs shall be inspected prior to any roofing material being installed.
0 Yes
Will
a roof is 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 n taterials for inspection.
strict?
0 Yes kj No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Cade,Sections 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
reyutrem hist must be met prior to issuance of a Certificate of Occupancy. Signature of Applicant Date
�,.----�� G�/5l 7� All roof coverings to be Class'W'or better
Owner or authorized agent Dam
C
090(p0U
-�af� CITY OF CUPERTINO
CITY OF
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN #30-6a,i� Date:
Building Address:
.755 /-�/
Mailing Address (if different from building address):
Owner's Name i Phone#:
HOA: (Exterior work only) es ❑ No
If yes, provide letter from HOA 11
Contractor: Phone-
Fax:
Contractor License#: Q
Cupertino Business License##:
Contact: / Phone:
Fax:
Residential [" Commercial ❑
Job Description:
,.,r����tr�� i�' ��► fes.�`' �zZ,�
Building Permit Info:
Bldg [I Elect D' Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Typ`e
e:
Q _
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V.-B d l
Valuation: 1
6d Q Square Footage:
Project Size: Express(EX Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicab:.e, include in plan set & the sheet index.
Points Achieved:
For help, contact Build it Green at www.builditR -een.or
Revised 02/05/09
a�nCITY OF CUPERTINO
CU
CITY
OF O GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Wir.dow-structural shear B
wall/mas:)nry (includes plan ck fee)
I EPERMITFEE Electrica Permit Fee E
1 MPERMITFEE Mecham,-,al Permit Fee M
1 PPERMITFEE Plumbing;Permit Fee P
1 ELCPLNCK Stand Al ane Electric Pln Ck (hourly) E
1 MECPLNCK Stand Al Dne Mechanical Pln Ck (hrly) M
1PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
I STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-s'and alone
r 1 BCBSC Cal Bld€; Standards Commission Fee B ALL PERMIT
TYPES
1 BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel & Documentation B
1BUSLIC Business; License B
5 of 5
M.Indoor Air auality and Finishes •
1.Use Leo-VOC Paint 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3.Use LowNe 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.SOW al .tgxoseld_Pa+ boull or MDF 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 i !
N.Flooring
1.Select FSC Certified Wood Flooring 3 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
1 1 !
Total Points Available: 1 1401 1301 57
Total Points Project Received:1 01 01 0
0
G:data/progs/gre-nbuiic ingguidelines/remodelers/greenpointsfina]2.12.04protected.xis
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CIV OF Fax(408)777-3333
rUPE�TINO
Building Department
JOB ADDRESS: '7!��/ -1—!�-�cJl s-r PERMIT # d
Gro q,
OWNER'S NAME: PHONE # --05
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and com Clete 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