09060151 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � t. �� �
PERMIT NO.
BUILDING ADDRESS:
20030 PACIFICA DR P V S ELECTRIC 09 151
PERMIT ISSUE DATE
OWNER'S NAME:
(408) 221-1785
BUILDING PERMIT INFO
ARCHITECI'/ENGiNEER:
BLDG ELECT PLUMB MECH
u p p LICENSED CONTRACTOR'S DECLARATION Job Description
oa I hereby affirm that I am licensed under provisions of Chapter 9(commencing
i with Section 70(10)of Division 3 of the Business and Professions Code,and my license is S ERVC U PGRD TO 240V/200A
y in full force and eff / w3
License Cl 4 Q L C.M
j:w Date Contractor
ARC ITECT'S DECLARA N /(
n.U I understand my plans shall be used as public records ' I�y
Lu
wy Licensed Professional
O e OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the ContraclOes License Law for the
i in O following reason.(Section 7031.5,Business and Professions Code:Any city or county
.CQ which requites a permit to construct alter,improve,demolish,or repair any structure
4.V Z> prior to its issuance,also requires the applicant for such permit to Glc a signed statement Valuation
x C that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 3q.Ft.Floor Area
Y.t— (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $1750
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($500). 36928029 . 00
Q 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 We(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law docs not apply to an owner of q p
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.).
Q 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 Caw docs not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a conuactor(s)licensed pursuant to the Contractor's
License Law.
Q 1 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-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
Q 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.
My Worker's Co teens tion Insurance carrier and Policy number are:
Carrier. Policy No.: 2
C RTTFICATE OF EXEMPTION FROM WORK S'
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,1 shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Caws 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
,J z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
(~� 1 hereby affirm that there is a construction lending agency for the performance of
R!> the work for which this permit is issued(Sec.3097,Civ.C.)
W Lenders Name
z Lender's Address
V 0 1 certify that 1 have read this application and state that the above information is
(L Centel.I agree to comply with all city and county ordinances and state laws relating to
building construction,and hereby authorise representatives of this city to enter upon the
0 U
Wshove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
CA liabilities,judgments,costs and expenses which may to an way accrue against said Cit
►�-�04 j g Pem Y Y Y g Y n
U Z in consequence of the granting of this permit. Date
■ APPLICANT UNDERSTANDS AN WILL O ALL NON-POINT Issued by:
SOURCE REGULATONS—
Re-roofs
Signature of Applicant/
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
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)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes p N.
// 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
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new rr aterials for inspection.
nstrict7 a /�
Q Yrs �T�PIo-
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safcty Code,Sections 255(15. 533 and;;P41_1 understand that if the building
docs not currently have a tenant that it is y respo lity otify the occupant of the
royuiremcntswh'
All roof coverings to be Class'J4`'or better
oto (t UI 1
CITY OF C.UPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # ��� � � U c) Date:
Building Address:
Mailing Address (if different from building address):
Owner's Name: �;�� � :
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from HOA
Contractor: Phone: 40� - ZZ�• ���5
C• ' .s --- C— Fax: 8
Contractor License#: ��g�4
Cupertino Business License#: 2, t,2�
Contact: v Phone: 4a!EL) •2.2.4 '�7j '
Fax:
Residential Commercial
Job Description: S t> cn.
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Type of Construction (Usage C ass): Occupancy Type:
I-A, I-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B [- V--7
Valuation: Square Footage:
0
Project Size: Express •'_Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set& the sheet index.
Points Achieved: „-�
For help, contact Build it Green at www.builditgreen.or
Revised 02/05/09
CITY OF CUPERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPEf�TINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Al)plications (up to 400 sf) B
additiona. 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 Mechanical Permit Fee M
1 PPERMITFEE Plumbin€, Permit Fee P
1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E
I MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
IPLMBLNCK 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-stand alone
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
l BSEISMICR Seismic JZesidential B
IBSEISMICO Seismic Commercial B
1 TRAVDOC Travel & Documentation B
IBUSLIC Business License B
5 of 5
M. n oor Air Quality and Finishes
1.Use Low/No-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 Low/No 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.Seal all Egiosed.f'a Waboard or MDF 4 IAQ/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 I0
1 1 1
N.Flooring
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: 1401 130 57
Total Points Project Received:: 01 1
G:data/progs/gre anbuildingguidelines/n:modelers/greenpointsfinal2.12.04proteried.xls
Community Development
10300 Torre Avenue
' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
''UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
ZOO`S 0 e--ECA 6
OWNER'S NAME: PHONE # GFpg 074
GENERAL CONTRACTOR:
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