09060028 CITY OF CUPERTINO
BUILDING DIVISION PERMITMal
BUILDING ADDRESS: PERMIT NO.
10192 PARISH PL AAA FURVACE & AIR 09060028
CONDITI DNING PERMIT ISSUE DATE
942 A A O. CONTROL NO.
(408) 293-4717
ABUILDING PERMIT INFO
RCH)TECT/BNGiNEER:
BLDG ELECT PLUMB MECH
y0p LICENSED CONTRACTOR'S DECLARATION Job Description
V I 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
in fullforeeandefje . RMV EXT FRNC, COIL, WTRHTR & INSTL UPFLW
Z Licen Iris _ Lic•M ? i
D
Date — Contractor B O�EFFC VT
ARCHITECTS DECLA ATION
09.< I understand my plans shall be used as public records 6 O, O O O B PU FURNC IN GARG, 3 TON COIL& C ONDENS R &
�yU
#w rF Licensed Professional 4 O
:yg OWNER-BUILDER DECLARATION GAL REHEEM WTR HTR, 7 SUPPLY REGISTERS
1 hereby affirm that It.exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
m 9 which requires a permit to construct.alter,improve,demolish,or mpair any structure
y Z y 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
r (commencing with Section 7000)of Division 3 of thc Business and Professions Codc)or $6750
y 5 F 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($5=. 31644037 . 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 Contractor's License Law does trot apply to an owner of q P
property who builds or improves thereon,and who does such work himself or duough 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
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 themon,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 Workees Compen-
.d)on,at provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section
39b0 of the Labor Code,for the performance of the work for which this permit is issued.
My Wo Com easation Insurance carrier and Policy number are:
Grtier 1 Policy No.:!Z l 3't) 2
CER IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less)
I cenifv 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
,J O forthwith 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
a the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lendces Name
Z L.cndees Address
V 0 1 certify that I have read this application and state that the above information is
[L u4 correct I agree to comply with all city and county ordinances and state laws relating to
Vbuilding conswction,and hereby a orize representatives of this city to enter upon the
W above-mentioned property for ins _ion purposes
a (Wc)agree to save,i Wily and keep harmless the City of Cupertino against
rA liabilities,judgmcnts,cos uses which may in any way accrue against said City a �y Cj
Z APPANT
nce of the g ng is permit. Date v
Re-roofs
Si of Applies' ontractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of F;oof
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.
❑Yes Z-No
Will the applicant or future building occupant use equipment or devices which
If a roof s installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
strict? C 17
Cl Yes fir• '�
1 have read the haza rials requirements under Chapter 6.95 of the Califor-
Dam All roof coverings to be Class';`'or better
Oq OLP o nk
CITY OF CUPERTINO
a10FURNACE/AC
CUPkINO PERMIT APPLICATION FORM
APN # �I I I n Date:
C)� 57--10 -�
Building A dress:
Z '--PGr�s"-, C e
Owner'
/
1 \a � AAA � Fax#: #e —01q, -fr 7"7
Contractor License#: Cupertino Business License#:
0,93 c2 7 (o � °slc�
Contact: Phone #:Z/-O? -q 2/7
n el r V Fax #: q6
Building Permit Info:
Elect Et] Plumb ER' Mech [-
Residential Commercial
Job Description: `eryloj-t <X—5,f ?r q r-14, C e, Co,L- tooter h e*Q �.-
JNS w 1I Vptl4W �d 66oz3TK �"l��-NKc.C. i�� 644rASe ► 3 ;bn ro;L C'anca✓�i�.s e
4- /1e r'j eey. h P� ' "1 I Q s Sites
For Residential Installations:
Attic ❑ 1 s` floor N 2°d floor ❑
Adhere to minimum setback requirement 51
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installatior. ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction (Usage Class):
'116 -7,-50 ,0 0 LZO
Strapped On Platform Bonded New Location Replacement
Project Size: Ex ress Standard ❑ Large [] Major ❑
Valuation:
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, incl ade in plan set & the sheet index.
Revised 01/07/09
CITY OF C'.UPERTINO
FURNACEAC
-UPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Descriptio:i Fee Permit Type
Group
FURNACE FURN/AC
1 MCRAA Commercial-Ref air/Alteration/Add to M
ea heating appliance,refrigeration unit,
cooling unit,ab sc rption unit,or ea
heating,cooling,zbsorption or
evaporative cool:ng system,incl
installation of co:ltrols regulated by this
code.
1 MCREPALT Commercial for i he repair of alt/add to M
ea heating appliance,refrigeration
unit,cooling unit.VAV boxes,
absorption unit or ea heathing, cooling
absorption,or ev�Lporative cooling sys,
incl install of controls regulated by
this code.
1MCSUSHTR Commercial Instill/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted unit heater.
1PGASCOM Commerical for ,:a gas piping System P
1-4 outlets
1 BPGAS For each gas pip:ng system of 5 or P
more per outlet.
1 MCAPPVNT Commercial for,:he install/relocate/ or M
replacement of ei appliance vent
installed ¬ incl in an appliance
permit.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
IBSEISMICO Commercial Sei:;mic B
1 MRRAA Residential Repz it/Alteration/Add to M
ea heating appliznce,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,,ibsorption or
evaporative cooling system,incl
installation of ccntrols regulated by
this code.
IMRSUSHTR Residential Install/Relocate ea M
suspended heate:•,recessed wall htr, or
floor mounted unit heater.
CITY OF CUPERTINO
D�v,
FURNACE/AC
CUPEI,TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
AIR FURN/AC
CONDITIONING
1 BCAIRHAN Commercial A/C Units <= 1 Ok CFM B
1 MCRAA Commercial Mech Repair/alt/add M
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Seismic Commercial B
1 PGASCOM Commerical for e i gas piping System P
1-4 outlets
1 PGASRES Residential for ea gas piping system P
of 1-4 Outlets
1BPGAS For each gas pining system of 5 or P
more per outlet. C',omm/Resid
1 BREMAIRHAN Residential A/C units<= l Ok CFM B
1 MRRAA Residential Mech Repair/alt/add M
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
/ 1BSEISMICR Seismic Resident al B
1 EPERMITFEE Electric Permit E
1MPERMITFEE Mechanical Permit M
1PPERMITFEE Plumbing Permit P
1 TRAVDOC Travel Documentation B
1BUSLIC Business License B
M.Indoor Air Quality and Finishes
1.the tovAgo-VOC P 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes. 0
3.Use Loaft VM Adh ss 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 allcsd3'.ar&eboaud.AaJADF 41AQ/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 1
N.Flooring
1.Select FSC Certified Wood Flooring i Resource pts y=yes 0
2.Use Rapidly Renewable Fboring Maferials 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
Total Points Available: 1 1401 1301 57
Total Points Project Received:1 1 01 01 0
G:datalprogslgre:nbuildingguidelines/remodelers/greenpointsfina12.12.D4protected.xls
Community Development
10300 Torre Avenue
' Cupertino CA 95014
Telephone(408)777-3228
CI7Y OF Fax(408)777-3333
"UPEkTINO
Building Department
JOB }ADDRESj: n PERMIT#
S(
OWNER'S NAME:
I am not using any subcontractors: -�—/
Signature Date
Please check applicable subcontractors and complete 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
Date
Owner/Contractor Si ture