09060043 7-777777777= -7:7777!:
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS: ��7�
L/Ll'1 ] PERMIT ISSUE DATE
OWNER'S NAME:
S A CONTROL NO.
PHO
408) 253-2447
BUILDING PERMIT INFO
..e.CH1TECTIENGiNEER: BLDG ELECT PLUMB MECH
a 0 a a
u p O LICENSED CONTRACTOR'S DECLARATION Job Description
jmI hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of the Business and Professions Code.and my license is
=y in full force and effRPLC EXPNG GAS SUPPLY .LINES W/NEW FM METER TO 2
D n? License Class Lie.M
&-a
Date Contractor FIXTRS x EXSTNG LINE BY WATER HEATER & NEW WATER
RCHrfECTS DELLA ATION
I understand my plans shall be used as public records HEATER - CONTRACTOR RNEW BSL #25864
4
Cy Licensed Professional
.3 OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
Pi 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
z< that he is licensed pursuant to tate provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
y (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
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). 37532057 . 01
❑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 docs 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
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's 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.
❑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:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
m,as provided for by Section 3700 of the Labor Code,for the performance of the
,rk 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 Co easadon Insurance carrier and Policy�number am:
Carrier
40C+J Polity No.:
CERTIFICATE OP EMPrION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or Icss)
1 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z, CONSTRUCTION LENDING AGENCY
I hereby alTrm 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 0 Lender's Name
Z Lender's Address
U 0 1 certify that I have read this application and state that the above information is
LL
0° con-ecL I agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
Lia above-mentioned property for inspection purposes
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
,F•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. at, (/
t--� APPLIC NT NDERSTANDS AN WJhL ALL NON-POINT Issued b)
Re-roofs
Sigidituic bl'ApplicutlConyactor Dare T Of Roof
MATERIALS DISCLO 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(a)? All roofs shall be inspected prior to any roofing material being installed.
❑yet 50-0
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
^mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new r laterials for inspection.
uict?
❑Yes tPLEP
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
Date
CITY OF C-,UPERTINO
REPIPE/SEWEIR/MAIN SERVICE
CUP IT
TINO PERMIT APPLICATION FORM
APN # v� v/ Date: , D
CJ
Building Address: _
!
:
Fax#: pQ', -
Contact: Phone#: yp6'— sef S--/ 3o �
'e, Fax#:
Contractor License
Cupertino Business License#:
p /olo ��Fs NJ�.
Job Description:// �S►S � � sy
/rf�Z � ' .l'� 245. �r �X�tS ! "'`g 6� b� ►�C� T74-
Residential Commercial ❑
Valuation:
Project Size: Express D Standard 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 bL.ilding P 1CPSS
sewer/sanitary sewer
1BPREPIPE Commercial re-pipe per fixture P 1CPRP
1PGASCOM Commercial Gis 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/SEWERTAAIN SERVICE
CUPEF�TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
j 1BCBSC Cal Bldg Standard,; Commission B ALL PERMIT
l Fee TYPES
1 1BSEISMICR Seismic Residentic.l P
1PRSEWER Residential building P 1RPSS
sewer/sanitary se A er
1PRREPIPE Residential re-pipe per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
1 BPFIXTURE Plumbing Fixture P
1PGASRES Residential Gas Piping System P
1-4 Outlets
1 BPGAS Gas Piping System 5+ Outlets P
1 PPERMITFEE Plumbing Permit Fee Issuance P
1PLMBLNCK Plumbing Plan Check P
1 PLMBINSP Other Plumbing/g is Insp. P
1TRAVDOC Travel & Documentation Fee B
( 1BUSLIC Business License B
1
M.Indoor Air Quality and Finishes
1.UseLoWN04OC 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 LowNb 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 all i prMP, oaml or tiff 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 0
N.Flooring
1.Select FSC Certified Wood Flooring E Resource pts y=yes 0
2.Use Rapidly Renewable Flooring Materials Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 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 D
Total Points Available: 1 1401 130 57
Total Points Project Received: 01 01 0
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t p -19:ibuilain uidelines/rOrs/g,?(, ,12.12.04protected.xls
Community Development
10300 Torre Avenue
t, Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
rUPEkTINO
Building Department
JOB ADDRESS: Or� PERMIT # o q o`P
OWNER'S N PHONE #
GENERAL
Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSI14ESS 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