09100057 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7453 KINGSBURY PL CONTRACTOR:BLASZCZYK MARK G PERMIT NO:09100057
OWNER'S NAME: BLASZCZYK MARK G DATE ISSUED: 10/08/2009
MR'S PHONE: 4088067131 CUPERTINO CA, 95014-5044 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:NEW WATER LINE&TIE INTO LINE FOR
(commencing with Section 7000)of Division 3 of the Business&Professions FUTURE 2ND
Code and that my license is in full force and effect. DWELLING;TIE INTO EXISTING SEWER FOR FUTURE 2ND
DWELLLING
1 hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,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 Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$500
permit is issued.
APPLICANT CERTIFICATION APN Number:36228001.00 Oc an Type:
I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating
to building constriction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF. T STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAY ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FRO LLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued-bye Date:tl
Signature Date
OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code).
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
1 certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must w o an or' ed agent: 0 �61
forthwith comply with such provisions or this permit shall be deemed revoked. Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
mify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18. j I understand my plans shall be used as public records.
Signa re Date` Licensed Professional
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 36228001 . 00
DATE ISSUED. . . . . . . : 10/08/2009
RECEIPT #. . . . . . . . . BS000008866
REFERENCE ID # . . . 09100057
SITE ADDRESS . . . . . : 7453 KINGSBURY PL
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER BLASZCZYK MARK G
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5044
RECEIVED FROM . . . . : MARK G BLASZCZYK
CONTRACTOR LIC # *OWNER*
COMPANY BLASZCZYK MARK G
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5044
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 500 . 00 1 . 00 0 . 00 1. 00 0 .00
1BPWSVCS WATER SERVICE 1 .00 21 .00 0 . 00 21. 00 0 .00
1BSEISMICR VALUATION 500. 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 127.50 0 . 00 127.50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER -
----------------- --------------- --------------------
CREDIT CARD 127 .50 AMEX
---------------
TOTAL RECEIPT 127 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 301 ROUGH PLUMBING
507 FINAL PLUMBING
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform:
A. All the work authorized by this permit
B. _ A portion of the work
C. _ None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. A portion of the work (complete section below)
[Contractor Address/City. Phone # State License # Type of work to
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer(see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City . Phone Number Type of work to be
performed
.......................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information(revere side). D/
Property Owners Signature: Date: [0 )2De
job Address: l� E Permit# bq
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
�o�
-. CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN# Date: lft� laq
Building Address:
Owner's Name: Phone#:
PA,
LA S _ZC
Contractor: Phone#:
Fax#:
Contact: Phone#:
Fax #:
Contractor License#:
Cupertino Business License#:
Job Description: fqf V,( VVA-M 1(- &iNF-- qF -774- //VTM LW E FV.*L,
ZnJV T)1/v,--L-L4 ry 4 7
'TE t N Ir V F_�c I STi,�✓ A 5S-&V&—$t— F::VK ONLD DVV6- ,)N
Residential —F)!� Commercial ❑
Valuation: 446-00
Project-Size: Expres — Sf-afidard Lj 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-pipe per fixture P 1CPRP
1 PGASCOM Commercial Gas Piping System P _
1-4 Outlets
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1 BSEISMICOM Seismic Commercial P
Revised 01/07/09
CITY OF CUPERTINO
alt-Vto REPIPE/SEWER/MAIN SERVICE
CUPEI�TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICR Seismic Residential P
/ 1PRSEWER Residential building P 1RPSS
sewer/sanitary sewer
1PRREPIPE Residential re-pipe per fixture P 1RPRP
% 1BPWSVCS Water Service P 1CPWS or
1RPWS
1 PPRSEWG 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
1 BPGAS Gas Piping System 5+ Outlets P
/ 1PPERMITFEE Plumbing Permit Fee Issuance P
1 PLMBLNCK Plumbing Plan Check P
1PLMBINSP Other Plumbing/gas Insp. P
1TRAVDOC Travel & Documentation Fee B
1BUSLIC Business License B
.In oor Air uality and ims es
1.Use Lm 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.Seat all ExposedP.,arbalefwardorMDF 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
1 1
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 0
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring B 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
1 1 1
Total Points Available: 1 1401 130 57
Total Points Project Received: . 0 0 0
G:datalprogs/greenbuildingguidelines/remodelers/greenpointsfinal2.12.D4prrnected.xls