09060026 CITY OF CUPERTINO
BUILDING DIVISION PERMIT Gt3TR �RI� ? TN*
BUILDING ADDRESS: PERMIT NO.
10896 LINDA VISTA DR FIROZ PRADHAN 09060026
OWNER'S NAME: PERMIT ISSUE DATE
r)lf 19? 1099
A A O. CONTROL NO.
ABUILDING PERMIT INFO
RCHITECr/ENGTNEER:
BLDG ELECT PLUMB MECH
q p LICENSED CONTRACTOR'S DECLARATION Job Description
UI hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 70(10)of Division 3 of the Business and Professions Code,and my license is
� y in full force and effect. INST NE9 AIR CONDITIONR, REPLCMNT OF FURNACE
? License Class Lic.k
E-
0 Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
�yU
u y Licensed Professional
n y< OWNER-BUILDER DECLARATION
1 hereby arm that I am exempt from the Contractors License Law for the
00 tLfollowing reason.(Section 7031.5,Business and Professions Code:Any city or county
K which requires a permit to construct,alter,improve,demolish,or repair any structure
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
yF- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $2100
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 ere hundred dollars(M). 35614045 . 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 Contractors License Law does not apply to an owner of (1 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,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
nstroct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense Caw 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.
❑lam B&P C for this reason
Owner Date 0�
RK O SATION DECLARATION
I hereby affirm un nalty of perjury one of the following declarations:
I 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
.ik for which this permit is issued.
❑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 Workers Compensation Insurance carrier and Policy number arc:
Cartier. Policy 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.)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any man bccom bjcct the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after e ' of Exemption,you should
become subject to the Workces Com uuati tsions of the Labor Code,you muni
Oforthwith comply with such provisions or is permit shall be deemed revoked.
z"'" CONSTRUCTION LENDING AGENCY
F~.t►�-� 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.)
QLenders Name
a z Lenders Address
V 0 I certify that 1 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
OVbuilding construction,and hereby authorim representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
W (We)agree to saw,indemnify and keep harmless the City of Cupertino against
Hto liabilities,judgments,costs and expenses which may in any way accrue against said City z n
(�Z in consequence of the granting of this permit. late
►. APPLICANT UNDERSTA COMPLY WITH ALL NON-POINT Issued :
SOURCE REGULATIONS
66/07 Re-roofs
Signature of Applicaft<0AGact Da1e T of Roof
HAZARD TERIALS DISCLOSURE Type
Will the applicant or 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 Wo
''`\ 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
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
erict?
❑Yes f'?No
1 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
docs not currently ha, a ten t that it' my responsibility to notify the occupant of the
requirements t et pri issuance ora Certificate of Occupancy. Signatur( of Applicant Date
All roof coverings to be Class''"or better
Owner or auth z d age Date
( L) C) �
CITY OF CUPERTINO
FUF24ACE/AC
CUPEI�TINO PERMIT APPILICATION FORM
APN # „ `� �� Date: 3
Building Address: 10 g 16 LINDA Vi5'm Dr, �Pckri uo, cA -15d i4,
Owner's Name:
:
0�N&� -- f;L)ILpa
Fax M
Contractor License#: Cupertino Business License#:
Contact: Phone#:
a S 0 Vr a--
Fax
CSFax #:
Building Permit Info:
Elect [`- Plumb Mech Efi
Residential 0 Commercial
Job Description:
n ,li1r,;Cf%,r►.
For Residential Installations:
Attic El15t floor 2"d floor Z
Adhere to minimum setback requirement
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction (Usage Class):
4 )-1 o 0 — k,/j3 -Strapped On Platform Bonded New Location Replacement
Project Size: Express ®—Standard ❑ Large 1] Major❑
Valuation:
Green Building: Please complete relevant portW.1 of the Green Building Checklist & attach it to the
application or if applicable, include in plan set& the sheet index.
Revised 01/07/09
CITY OF C,UPERTINO
FURNACE/AC
CUPE�TiNO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
FURNACE FURN/AC
1 MCRAA Commercial-Repz.ir/Alteration/Add to M
ea heating applian ce,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,absorption or
evaporative cooling system,incl
installation of controls regulated by this
code.
1 MCREPALT Commercial for the repair of alt/add to M
ea heating appliarLce,refrigeration
unit,cooling unit,JAV boxes,
absorption unit or ea heathing, cooling
absorption,or eva)orative cooling sys,
incl install of con 7ols regulated by
this code.
1 MCSUSHTR Commercial Instz.11/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted unit heater.
1PGASCOM Commerical for ca gas piping System P
1-4 outlets
1 BPGAS For each gas pipi:ig system of 5 or P
more per outlet.
1MCAPPVNT Commercial for the install/relocate/ or M
replacement of epi appliance vent
installed ¬ ir cl in an appliance
permit.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Commercial Seismic B
1MRRAA Residential Repair/Alteration/Add to M
ea heating appliance,refrigeration unit,
t cooling unit,abscrption unit,or ea
J1 heating,cooling,z b sorption or
evaporative cool ging system,incl
installation of controls regulated by
this code.
1MRSUSHTR Residential Install/Relocate ea M
suspended heate:-,recessed wall htr, or
floor mounted unit heater.
CITY OF C UPERTINO
FURNACE/AC
CITYCUPEF�TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Grou
AIR FURN/AC
CONDITIONING
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 Commercial B
1PGASCOM Commerical for ca gas piping System P
1-4 outlets
1PGASRES Residential for e�L gas piping system P
of 1-4 Outlets
1BPGAS For each gas pi;)ing system of 5 or P
more per outlet. Comm/Resid
1BREMAIRHAN Residential A/C-znits<= IOk CFM B
/ 1 MRRAA Residential Mech Repair/alt/add M
f
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
1 EPERMITFEE Electric Permit E
1 MPERMITFEE Mechanical Permit M
1 PPERMITFEE Plumbing Penni- P
1 TRAVDOC Travel Documer.tation B
1BUSLIC Business Licens,; B
INPUT Resources Energy A!
M.Indoor Air Quality and Finishes
1.Use Low/No-VOC Paint 1 IAQ/Health pts y=yes 0
2.Use Low VOID,Water-Based Wood Finishes 2 IAQ/Health pts y--yes 0
3.Use LowMo 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 3IAQ/Health pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7.Seal all Exposed Particleboard or MDF 4 IAQ/Health pts y=yes 0
S.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 I0
. 1 1 !
N.Flooring
1.Select FSC Certified Wood Flooring E Resource pts y=yes 0
2.Use Rapidly Renewable Flooring Materials i Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles i 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 ! old
Total Points Available: 1401 1301 571
Total Points Project Received: 01 0 0
G:data1progs1greenbuildingguidelines/remodelers/greenpointsfina 12.1 p6iected.xls
OWNER-BUILDER VERIFICATION �
OWNS � ^
1. (Check one) I or my immediate family 1parent,spouse or child) will perform:
A. 2- All.the work authorized by this permit
B. A portion of the work
C. — None of the work
If B or C is checked,c:)mplete 2 or 3 below.
2. A state licensed contractor will be hired.to do:
A. All of the work
B. A portion of the work (complete section below)
Contractor Address/City. Phone # State License # Type of work to
L.... --C---A
3, _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
persogTirm Address/City . Phone Number Type of work to be
performed
..........................................................................................
I declare ander penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information ( .
-� Date:
Property Owners Signature:
Job Address:
��k j6 L,,v,� lfsi-�1 +,� G�P� �i�✓� Permit#
--r
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
Community Development
10300 Torre Avenue
a... Cupertino CA 95014
Telephone(408)777-3228
CITY OF
Fax(408)777-3333
%KkTINO
Buildin De artment
JOB ADDRESS: PERMIT # r'1 / U
V-157-71 ��R cviTiNc, cs1 s tD
OWNER'S NAME: PHONE # &I -2-e s2
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: '�'
re Date
Please check applicable subcontractors an com Mete 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