09070075 CITY OF CUPERTINO
BUILDING DIVISION PERMITN- Ft� MT �N.
BUILDING ADDRESS: PERMIT NO.
22434 RIVERSIDE DR JACK FYERS CQLIqTRIJCTTON 09070075
"VNER'S NAME: PERMIT ISSUE DATE
PHONE: SAN A CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
DEMO LEAKING SHOWER, REDOme Z
o o D O
0
u0 LICENSED CONTRACTOR'S DECLARATION SHOWER WITH DURAROCK
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z 5 with Section 7000)of Divisipn 3 of the Business and Professions Code,and my license is
y in full force and effect 1 L
? License I s Lic.#
Date Contracwr0D2
ARCHITECTS DEC ON
C< 1 understand my plans shall be used as pubWc records
�yrJ
L.0 Licensed Professional
y OWNER-BUILDER DECLARATION
X 1 hereby affirm that I am exempt from the Contractors License Law for the
in O following reason.(Section 7031.5,Business and Professions Code:Any city or county
,c which requires a permit to concoct,alter,improve,demolish,or repair any structure
y z prior to its issuance,also requires the applicant ror such permit to file a signed statement
=C that he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9 Sq.Ft.Floor Area Valuation
Y F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
A 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).
❑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 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.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
ccnse 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
vnerDate
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 Workers Compen-
r n,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 am:
Carrier. 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 Icss)
I certifv that in the performance of the work_kr which thi rmit is issued.I shall not
employ any person in any asto Wo n
Laws of Calif ' .Da
Applicant
NOTICE TO C :If,after making crtnate of Exemption,you should
become subj to the orkcr's Compensaddh provisions of the Labor Code,you must
O forthwith comply with such provisions or this permit shall be deemed mvokcd.
Z�"t CONSTRUCTION LENDING AGENCY
E-t I hereby affirm that there i a cons gip lending agency for the performance of
fYr the work for whi permit' 7,Civ.C.)
W�0 Lenders Namc
a Lenders Add
U O 1 certify that 1 have read this application and state that the above information is
LL�- cored 1 agree to comply with all city and county ordinances and state laws relating to
0 building concoction,and hereby authorize representatives of this city to enter upon the
V
>4 W above-mentioned property for inspection purposes
1n. (We)agree to save,indemnify and keep harmless the City of Cupertino against
t2 liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit.
APPLICANT UNDERS ANDS AN WILL COMPLY WITH ALL NON-POINT Issued by: Date `[
SOUR EGULATI S
Re-roofs
Sign of Applicant/Contractor arc
HAZARD S MATERIALS DISCLOSURE Type of R)of
Will the applicant or fast building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
4c,Section 25532(a)? All roofs E hall be inspected prior to any roofing material being installed.
❑Yes No
Will the applicant r future building occupant use equipment or devices which If a roof i, 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 materials for inspection.
District?
❑Yes KN.
1 have read the hazardtnu materials requirements under Chapter 6.95 of the Califor-
nia Health&SafetyCodc,Sections 25505,25533 and 25534.1 understand that if the building
doFE�
e a ant that itisresponsibility to notify the occupant of the
re me uance of a certificate of Occas Signature )f Applicant Date
Oworaulhorizcdagcnt re All roof coverings to be Class'Aj'or better
Community Development
10300 Torre Avenue
~' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
CUPEI�TINO
Building Department
JOB A DRE .. PERMIT # (^�
fD 7 0�J
O R'S NAME: PHONE #
GE RAL CONTRACTO G FAX # -6 73
I am not using any subcontrac ors:
Si,;nature at
Please check applicable subcontractor d 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
D e
er/Contractor ature
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIZ RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk : Lot:
APN . . . . . . . . : 35E02004 . 01
DATE ISSUED. . . . . . . : 07/07/2009
RECEIPT #. . . . . . . . . : BSC00008151
REFERENCE ID # . . . : 09C70075
SITE ADDRESS . . . . . : 22434 RIVERSIDE DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . . RYFN YASUI
ADDRESS . . . . . . . . . . : 22434 RIVERSIDE DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : JACK MYER
CONTRACTOR . . . . . . . : JACK MYERS LIC # 24312
COMPANY . . . . . . . . . . : JACK MYERS CONSTRUCTION
ADDRESS . . . . . . . . . . : 27E10 NATOMA RD
CITY/STATE/ZIP . . . : LOE ALTOS HILLS, CA 94022
TELEPHONE . . . . . . . . : (4C8) 761-1185
FEE ID UNIT QUANTITY FMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- -- -------- ---------- ---------- ----------
1BCBSC VALUATION 10, 000. 00 1. 00 0. 00 1. 00 0 . 00
1BSEISMICR VALUATION 10, 000 . 00 1 . 00 0. 00 1 . 00 0 . 00
1SUPINSFEE HOURS 1. 00 126 . 00 0. 00 126 . 00 0 . 00
1TRAVDOC FLAT RATE 1. 00 42 . 00 0. 00 42 . 00 0 . 00
-- -------- ---------- ---------- ----------
TOTAL PERMIT 170 . 00 0 . 00 170. 00 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 170 .00 master card
---------------
TOTAL RECEIPT 170 . 00
CITY OF I..UPERTINO
CITY OF
CUPEkTINO GENERAI_j BUILDING
PERMIT APPLICATION FORM
APN # V `,+6 Zo/ Date: � � C
Building Address: 0'f
q ✓
Mailing Address (if different from building address):
Owner's Name: Phone#-
�s �9 4 -/
HOA: (Exterior rwotk only) las ❑ No
If yes, provide letter from HOA
Contr ctor: oe Phone:
Fax:
Co actor License
Cupertino Business License#:
Contact: Phone:
Fax:
Reside ial Commercial
Job Description: CL2''hLd`-
Building Permit Info: ell
Bldg C' Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-l3 ([ —
Valuation:/D Square Footage:
Dov
Project Size: Express R1 Standard ❑ Large [] Major ❑
Ir I
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicablf, include in plan set& the sheet index.
Points Achieved:
For help, contact Build it Green at www.buildit re en.or
Revised 02/05/09
- CITY OF C.UPERTINO
CITY of GENERAL BUILDING APPLICATION
CUPE�TINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco A;)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
I PPERMITFEE Plumbing Permit Fee P
1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1 PLMBLNCK 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-st�md alone
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
I BSEISMICR Seismic F.esidential B
1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel & Documentation B
1BUSLIC Business License B
5 of 5
M.Indoor Air QuaI4 and Finishes
1.Use Low/No-VOC Pa.1nt 1 IADJHealth 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 D
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes p
6.Use Exterior Grade Plywoodfor Interior Uses 1 IAQ/Health pts y=yes p
7.%al all Exposed Particleboard or MDF 4 IAQ/Health. pts y=yes 0
8.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
� E D
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: 140 1301 57
Total Points Project Received:1 1 01 01 Q
G:data/progslgre:nbuildingguidelines/remodelers/greenpointsfinal212.04protected.xls