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09070044 CITY OF CUPERTINO PERMIT �` BUILDING DIVISION PERMIT t*� L � �T � BUILDING ADDRESS: PERMIT NO. 10749 BROOKWELL DR H & H CO WNER'S NAME: PERMIT ISSUE DATE PHO : A CONTROL NO. 408) 221-7777 ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH u p a LICENSED CONTRACTOR'S DECLARATION Job Description mI hereby affirm that I am licensed under provisions of Chapter 9(commencing Z Lu with Section 7000)of Division 3 of the Business and Professions Code,and my license is =y in full force ande?ct.1O S ? REPLC S];WER LINE j vn Z License Class `' � _ Lle-0 .^ _c Date `G'�Contractor l ARCHITECTS DECLARATION I understand my plans shall be used as public records 7yU iC y Licensed Professional y OWNER-BUILDER DECLARATION n 1 hereby affirm that 1 am exempt from the Contractors Uccnse Law for the p O following reason.(Section 7031.5,Business and Professions Code:Any city or county R.9 which requires a permit to construct,alter,improve,demolish,or repair any structure yZ�' prior to is issuance,also requires the applicant for such permit to file a signed statement =C that he is licensed pursuant to the provisions of the Contractors license law(Chapter 9 .3q.Ft.Floor Area Valuation t— (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 3 O O 0 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 net more than five hundred dollars(M). 3 6 9 210 0'7 . 00 ❑1,as owner of the property,or my employees with wages as thew sole compensation, will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required fired Ins ecti ons and Professions Code:The Contractors License Law does 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 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 Contractors 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 Contractors License Law. ❑I am exempt under Sec. B&P C for this reason vner Dare WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: ❑I have and will maintain a Certificate of Consent to self-insure for Workers Compen- sation,as 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 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. Sfax 4Z#+� Policy No.:IS CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($I00) or less.) I certify that in the performance of the work for which this permit is issued,l shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California Datc 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 [~-t col 1 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.) (Sa Q Lender's Name 7 Z Lenders Address U C) 1 certify that I 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 0 V building construction,and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. W W (We)agree to save,indemnify and keep harmless the City of Cupertino against „Hr liabilities,judgments,costs and expenses which may in any way accrue against said City V Z in consequence of the granting of this permit Date 7 v APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SOURCE ULATIO Re-roofs Signature of Applican for Dale T of R sof 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 ')dc,Section 25532(a)? All roofs:;hall be inspected prior to any roofing material being installed. C3 Yes 01Z Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new m iterials for inspection. District? ❑Yes Nu I have read the hazardous materials requirements under Chapter 6.95 of thc Califor- nia Health&Safety Code,Sections 25505,25533 and 75534.1 understand that if the building does not currently have a tenant,that it is my responsibility to notify the occupant of the requirements wh'h must be met prior to issuance ora certificate of Occupancy. Signature of Applicant Date All roof coverings to be Class''{ or better Ownerorized agent Date Community Development ' 10300 Torre Avenue .' Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 CUPEkTINO Building Department JOB ADDRESS: /0 ?Y9 �\ ` PERM��0 cr OWNER'S NAME: Ge iuc M c Q WlC PHONE # GENERAL CONTRACTOR: +A 4 FAX # °f' I am not using any subcontractors: SignaDate 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 Tile Owner/Crtr r Signature Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN 36921007 . 00 DATE ISSUED. . . . . . . : 07/06/2009 RECEIPT #. . . . . . . . . BS000008135 REFERENCE ID # . . . : 09070044 SITE ADDRESS 10749 BROOKWELL DR SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER MCGHIE DUANE B AND GENE M ADDRESS 10749 BROOKWELL DR CITY/STATE/ZIP . . . : CUFERTINO CA, CA 95014-4608 RECEIVED FROM . . . . : SEAN A FRY CONTRACTOR ROE HERRICK LIC # 22876 COMPANY H & H CO ADDRESS 13990 MURPHY AVE CITY/STATE/ZIP . . . : SAID MARTIN, CA 95046 TELEPHONE (4C8) 224-7777 FEE ID UNIT QUANTITY FMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 3, 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 3 , 000 .00 0 . 50 0 .00 0 .50 0 .00 1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 1PRSEWER UNITS 1 .00 21 . 00 0 . 00 21 . 00 0 . 00 1TRAVDOC FLAT RATE 1 .00 42 . 00 0 .00 42 . 00 0 . 00 -- -------- ---------- ---------- ---------- TOTAL PERMIT 106 . 50 0 . 00 106 .50 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 106 . 50 VISA --------------- TOTAL RECEIPT 106 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING M.Indoor Air Quality and Finishes 1.Use L*wMo-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/W 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 aill bpried Parfdaboaid or MDF 4 IAQ/Health. pts y=yes 0 B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes D 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 t ! 6 N.Flooring 1.Select FSC Certified Wood Flooring B Resource pts y=yes 0 2 Use Rodly 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 1 f f Total Points Available: 1401 1301 57 Total Points Project Received: 0 0 0 G:data/progs/gre:nbuildingguidelines/ramodelers/greenpointsfina12.12.D4protected.xls CITY OF CUPERTINO "s REPIPE/SEWS R/MAIN SERVICE CUPEi�TINO PERMIT APPLICATION FORM APN # 3 (., � � � � O� ` Date: ✓� c�' Building Address: Owner's Name: Phone#: C- Contractor: Phone#: 1C1� �-� '92,9 �f (70c�� - - t Fax #: Contact: �""� Phone#: e{ � Fax #: 79 Contractor License#: � Cupertino Business License#: Job Description: Residential Commercial ❑ Valuation: Project Size: Express Standard 0 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 building P 1CPSS sewer/sanitary sewer 1BPREPIPE Commercial re-ripe per fixture P 1CPRP 1PGASCOM Commercial Gas Piping System P 1-4 Outlets 1BCBSC Cal Bldg Stand�Lrds Commission B ALL PERMIT Fee TYPES 1BSEISMICOM Seismic Commorcial P Revised 01/07/09 CITY OF CUPERTINO T REPIPE/SEWER/MAIN SERVICE CUPERTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group I 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICR Seismic Residential P 1 PRSEWER Residential building P 1RPSS sewer/sanitary sewer 1PRREPIPE Residential re-pips:per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1RPWS 1PPRSEWG Private Sewage Disposal System P 1 PCESS Cesspool P 1BPWATER Install/alter Water Pipe P 1 BPFIXTURE Plumbing Fixture P 1PGASRES Residential Gas Piping System P 1-4 Outlets 1BPGAS Gas Piping System 5+ Outlets P 1PPERMITFEE Plumbing Permit I-ee Issuance P 1PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/gas Insp. P 1TRAVDOC Travel & Documentation Fee B 1 BUSLIC Business License B