09070135 CITY OF CUPERTINO T
BUILDING DIVISION PERMIT � TRE�
BUILDING ADDRESS: PERMIT NO.
21483 SHANK ALLIED .
OWNER'S NAME: PERMIT L95UE DATE
--,T-.IApal DR 5: cisiT 2
ONE: S A CONTROL NO.
(408) 931-8844
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u O pLICENSED CONTRACTOR'S DECLARATION
U p I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z W with Section 7000)of Division 3 of the ByW and Professions Cade,and my lie
'�z Ueull force lL7 CLic.8 RMV/RPR FURNC & ADD A/C
D
=^q Date Contractor
�i 777 ARCHrrECTS DECLA •TION
oZ
-<4 I understand my plans shall he used as publi records
DWU
u y Licensed Professional
n y OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
n o following reason.(Section 7031.5,Business and Professions Code:Any city or county
K m P which requires a permit to construct,alter,improve,demolish,or repair any structure
uZy 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 3q.Ft.Floor Area Valuation
yF-$ (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or
y .. that he is exempt therefrom and ate basis for the alleged exemption.Any violation of $4000
Section 7031.5 by arry applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500). 36201003. 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
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
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 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 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.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor�Cadc,or the performance of the work for which this permit is issued.
Cam My orke AZ►'6C ce carrier and lacy No nuptge :,
Poli Nor/
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ibis 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,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 invoked.
Z" CONSTRUCTION LENDING AGENCY
[~i
4 I hereby M.that there is a construction lending agency for the performance of
p; the work for which this permit is issued(Sec.3097,Civ.C.)
WG1.Q Lendces Namc
►7Lender's Address
U 0 1 certify that 1 have read this application and state that the above information is
L>;," 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
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
nF,r t;,n liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z iMEE—
ng of this permit. y
D WILL PLY WITH ALL NON-P NT Issued b Date
Re-roofsfor Date
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(x)? All roofs:hall be inspected prior to any roofing material being installed.
❑Yes pivo
Will If a roof is installed without first obtaining an inspection,I agree to remove
ll the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes eqz
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Cade,Sections 25505.25533 and 25534.1 understand that if the building
docs not curtently have a tenant,thatit is ibiln notify the occupant of the
requirement; tch b t psi . ssuance o a tc0 Signature of Applicant Date
Owner or a xcd agent Dam All roof coverings to be Class'JT'or better
CITY OF CUPERTINO
7 ITEMS OF 7 PERMIZ RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk : Lot :
APN . . . . . . . . : 36201008 . 00
DATE ISSUED. . . . . . . : 07/17/2009
RECEIPT #. . . . . . . . . BSC00008215
REFERENCE ID # . . . : 09C70135
SITE ADDRESS . . . . . : 21483 SHANNON CT
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : LIANIDES CHRIS
ADDRESS . . . . . . . . . . : 21483 SHANNON CT
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : ALLIED AIRE SVC INC
CONTRACTOR . . . . . . . : STEINER, ARNOLD R LIC # 19207
COMPANY . . . . . . . . . . : ALLIED AIRE SERVICE INC
ADDRESS . . . . . . . . . . : 470 S HILLVIEW DR
CITY/STATE/ZIP . . . : MILPITAS, CA 95035
TELEPHONE . . . . . . . . : (408) 934-8844
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 4, 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 4, 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1EPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
1MPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
1MRRAA UNITS 1 . 00 63 . 00 0 .00 63 . 00 0 . 00
1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
1TRAVDOC FLAT RATE 1 .00 42 . 00 0 . 00 42 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 232 . 50 0 . 00 232 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 232 .50 #20869
---------------
TOTAL RECEIPT 232 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
CITY OF C UPERTINO
aft FURNA.CEAC
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
AIR FURN/AC
CONDITIONING
1 BCAIRHAN Commercial A/C Jnits <= l Ok CFM B
1 MCRAA Commercial Mech Repair/alt/add M
1BCBSC Cal Bldg Standarc!'Ls Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Seismic Commercial B
1PGASCOM Commerical for ea gas piping System P
1-4 outlets
1 PGASRES Residential for ea gas piping system P
of 1-4 Outlets
1 BPGAS For each gas piping system of 5 or P
more per outlet. C omm/Resid
1BREMAIRHAN Residential A/C units<= IOk CFM B
1 MRRAA Residential Mech Repair/alt/add M
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
1 EPERMITFEE Electric Permit E
1 MPERMITFEE Mechanical Perm:t M
+ 1 PPERMITFEE Plumbing Permit P
I 1 TRAVDOC Travel Documentation B
1BUSLIC Business License B
NPUT Resources Energy IAC'Heafth
M.Indoor Air Quality and Finishes
1.Use LowMo-VOC Pain 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 3IAQ/Heaith pts y=yes 0
D
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes
7.Seal 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
N.Flooring
1.Select FSC Certified Wood Flooring E 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 ',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 ! Mimi
Total Points Available: 1401 130 57
Total Points Project Received: c� 01 01 0
G:data/progs/ eer buildingguidelines/remod , e pointsfinal .12.04protectedxls
Community Development
10300 Torre Avenue
Y, Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
,UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
��,..V.-vcw 0,'o7D 13-5
OWNER'S NAME: PHONE # //
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: I fez- 02
Si,
;nature 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
Tile
Owner/Contractor Signature Date