09060050 CITY OF CUPERTINO
BUILDING DIVISION PERMITI� R�� IZ� I
PERMIT NO.
BUILDING ADDRESS:
PERMIT ISSUE DATE
OWNER'S NAME:
A CONTROL NO.
BUILDING PERMIT INFO
ARCHI'fECTIENGINEER: BLDG ELECT PLUMB MECH
q p C LICENSED CONTRACTOR'S DECLARATION Job Description
U P I hereby affirm that I am licensed under provisions of Chapter 9(commencing
IOU with Section 70(10)of Division 3 of the Business and Professions Code,and my license is
'may in full foNX
y tj � WINDOW&?ATIO DOOR REPLCMNT, REPLC 2PATI0 DOORS
License - W/OUGOI:QG FRENCH DOORS& INSTL NEW STOOPS W/1" MAX
I-p Dalc ARCHI7ECI'S DECLARATION
i j i understand my plans shall be used as public records DROP, I:QSTL 8 NEW WINDOWS LIKE 4 LIKE,
0
4 G Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
00 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 Ft.Floor Area Valuation
?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 S(1
YH (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 Occupancy Type
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of APN Number
not more than five hundred dollars(5500). 36933020 . 00
0 I•u owner of the property,or my employees with wages as their sok compensation,
will do the work and the structure is not intended or offered for sak(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 arc 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.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Conaactoes U'
cense Law does not apply to an owner of properly who builds or improves thereon,and,
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
0 I am exempt under Sec B&P C for this reason
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-
..,on,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
J 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 which this permit is issued.
N Workers Compensation cagier and Polity number am:
Carrier�j - O_6lti�l�w•/4 Polity No.: ;;t1G0
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for ono hundred dollars($100)
or less.)
1 certifv 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 Workers Compensation provisions of the Labor Code,you must
,J Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[�►N-. I hereby affirm that there is a construction lending agency for the performance of
p; the work for which this permit is issued(Sec.3097,Civ.C.)
W ALenders Name
0Z
Lenders Address
U C) I certify that I have read this application and sate that the above information is
4L correct.1 agree to comply with all city and county ordinances and sate laws relating to
U building construction,and hereby authorize representatives of this city to enter upon the
0
0W above-mentioned property for inspection purposes.
t7. (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
U Z in consequence of the granting of this permit. Date 65;►-4 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued
Re-roofs /
Signature of Applicant/Contractor are T of 1 Wof c/
HAZARDOUS MATERIALS DISCLOSURE Type
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(x)? All roofs shall be inspected prior to any roofing material being installed.
0 Yes R No
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
hazardous air contaminants as defined by the Bay Area Air Quality Management all new r laterials for inspection.
.rict7
0 Yes Me
1 have read the ha=tous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 undersand that if the building � �� D (l7
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
regai of a Certificate of Occupancy. Signature,of Applicant Date
_1All roof coverings to be Class'W'or better
Owne or authorized agent WaLc
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fat CITY OF CUPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APP]--jICATION FORM
APN # . 0 Date: 6/9/ol
Building Address: I ov-& �
Mailing Address (if different from building address)
Owner's Name;-
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from HOA
Contractor: �u �1 -` ,, a Phone: 40g—
Fax: r'f 0 't—to t,
Contractor License#: (o 6
Cupertino Business License#:
Contact:-17 � Phone: qC6�j Z 6U��
7 Fax:
Residential Commercial ❑
Job Description:: !?
tvvec�-
Building Pe it Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A5 1-B ❑ II/III/V-A Et IUIII B, IV-HT, V.-BE]
'
Valuation: 15" Square Footage: /1706
vo�
Project Size: Express [ tandard ❑ 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.buildits! een.or
Revised 02/05/09
CITY OF CUPERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPEkTINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1 STUCOAP Stucco Applications (up to 400 sf) B
addition,.l stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Window-structural shear B
wall/masonry(includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechani Sal Permit Fee M
1 PPERMITFEE Plumbin,;Permit Fee P
1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-si and alone
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
' l BSEISMICR Seismic (residential B
1 BSEISMICO Seismic Commercial B
1 TRAVDOC Travel &: Documentation B
1BUSLIC Busines,, License B
5 of 5
M.Indoor Air Quality 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 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
0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes
7.Seal d EVosW Particleboard or MDF 41AQ/Health. pts y=yes 0
B.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
I1 1 !
N.Flooring M
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: 1 1401 130 57
Total Points Project Received: 01 01 0
G:data/progs/gn enbuildngguidelines/remodelers/greenpointsfinal2.12.04protected.xls