09100150-EXPIRED,J
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10200 MILLER AVE BLDG A
CONTRACTOR: TBD - TO BE DETERMINED
PERMIT NO: 09100150
OWNER'S NAME: RODNEY BERGMAN
DATE ISSUED: 10/22/2009
OWNER'S PHONE: 8108152469
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
r r—
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. #
MECH T_ RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: CREATING AN 8SQFT SPACE FOR A
(commencing with Section 7000) of Division 3 of the Business & Professions
WASHEER/DRYER FROM
Code and that my license is in full force and effect.
AN EXISTING CLOSET; NO RE -ROOF & NO STRUCTURAL
I 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.
Sq. Ft Floor Area:
Valuation: $6400
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
permit is issued.
APN Number: 37503005.BLDGA
Occupancy Type:
APPLICANT CERTIFICATION
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 construction, and hereby authorize representatives of this city to enter
PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs, and expenses which may accrue against said City in consequence of the
180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18•
Issued Date'�-�"�e
Signature Date
OWNER -BUILDER DECLARATION
RE -ROOFS:
rhereby
All roofs shall be inspected prior to any roofing material being installed. If a roof is
affirm that I am exempt from the Contractor's License Law for one of
installed without first obtaining an inspection, I agree to remove all new materials for
wing two reasons:
inspection.
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,
Signature of Applicant: Date:
Business & Professions Code)
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:
HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self -insure for Worker's
I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation, as provided for by Section 3700 of the Labor Code, for the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
performance of the work for which this permit is issued.
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
I have and will maintain Worker's Compensation Insurance, as provided for by
Safety Code, Section 25532(a) should I store or handle hazardous material.
Section 3700 of the Labor Code, for the performance of the work for which this
Additionally, should I use equipment or devices which emit hazardous air
permit is issued.
contaminants as defined by the Bay Area Air Quality Management District I will
maintain complian a with the Cupertino Municipal Code, Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued, I shall
Health & Safety ode, Sections 25505, 25533, and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of Califomia. If, after making this certificate of exemption, I
O orized t:
ne o
become subject to the Worker's Compensation provisions of the Labor Code, I must
Date: 6 Z Z d y
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is
for which this permit is issued (Sec. 3097, Civ C.)
correct. I agree to comply with all city and county ordinances and state laws relating
Lender's Name
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
ARCHITECT'S DECLARATION
with all non -poi source regulations per the Cupertino Municipal Code, Section
I understand my plans shall be used as public records.
9.18.
Date
Licensed Professional
Signature
,J
CITY OF CUPERTINO
ADDITION/REMODEL
CUPERTINO PERMIT APPLICATION FORM
APN # 4t U % pC
Date:
Ir, >
,
Is a 2" unit being added? Yes ❑ No If yes, please fill out the permit application for 2 no unit.
Building Address: t d 12,067 VVjt 12— A
Mailing Address (if different from building address):
Owner's arae:
Phone #
Contracto : ✓T
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Phone #:
Fax #:
Contractor License #: 8G 0__e7 �.
Cupertino Business License #:
Contact:
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Phone #: L�� 'a0 q _ / aq
Fax #: TZ-"
Building Permit Info:
Bldg. 0 Elect. Plumb. Mech. ffB__ Hillside ❑
Job Description:
Addition -What is being added?(Be Specific):
What is being remodeled (not including addition)? 7NV,5�
A why t:'�/ 1, y w- gv " - ," ,-�; �►.� C.. C_U'*.>VT
Remodel Includes Re -Roof. Yes ❑ No If yes list number of squares
Remodel Includes Structural: Yes ❑ No
Do you have the pre -application planning approval? Yes ❑ No ❑
If yes, please provide a copy of your planning approval letter. Planners name:
Square Footage:
Addition: Porch: Deck: Garage: Detached Attached
Remodel: Kitchen Bath Other_
Type of Construction (Usage Class):
Occupancy Type:
'_13
1-A, 1-B ❑ II/IIIJV-A ❑ IUIII B, IV -HT, V -B ®
Valuation:�b�
Please check this box if the project is a
second -story addition ❑
Project Size: Express E Standard ❑ Large ❑ Ma'or ❑
Please complete relevant portion of the Green Building
Checklist & attach it to the application or if applicable,
Green Building Points Achieved: d
include in plan set & the sheet index.
***For Office Use Only***
Over -the -Counter ❑ Revised 07/06/09
-t J
CITY OF
CUPERTINO
CITY OF CUPERTINO
ADDITION/REMODEL
FEE SCHEDULE
Quantity
Sq Ft
Fee ID
Fee Description
Fee Group
Permit Type
ADDITIONS
1R3SFDADD
1 PLLONGRNGR
Long Range
Planning/Residential
PL
1R31NSP
Dwellings Inspections
B
1R3PLNCK
Dwellings plan check
B
1R3REPINSP
Dwellings Repeat
Inspection
B
1 R3REPPLNC
Dwellings Repeat Plan
Check
B
1 R3HINSP
Dwellings Hillside
inspection
B
1R3HPLNCK
Dwellings Hillside plan
check
B
1 R3HREINSP
Dwellings Hillside
Repeat Inspection
B
1R3HREPLNC
Dwellings Hillside
Repeat Plan Check
B
1 R3ALTINSP
Dwellings Alternate
Materials Inspection
B
1R3ALTPLNC
Dwellings Alternate
Materials Plan Check
B
1 PCESS
Cesspool
P
1PPRSEWG
Ea. Private Sewage
Dis osal System
P
1 PRSEWER
Sewers
P
1 BPSPRINK
Lawn Sprinkler/Backflow
P
1BPWSVCS
Main Water Service
P
j
I
1 BCBSC
Cal Bldg Standards
Commission Fee
B
ALL PERMIT TYPES
1BSEISMICRE
SeismicResidential
B
1REROOFRES
Residential Re -roof Each
100 SF
B
CITY OF CUPERTINO
ADDITON/REMODEL
FEE SCHEDULE
Quantity
Fee ID
Fee Description
Fee Group
Permit Type
Sq Ft
DECKS
1R3SFDADD OR
1R3SFDREM
1 DECKWOOD
Deck (Wood) -Each
B
(Each)
1 DECKRAIL
Deck Railing -Each
B
(Each)
GARAGES
IR3SFDADD OR
DETACHED
1R3SFDREM
1 GARDTW<=1 K
Wood Frame up to
B
1,000 SF (each)
1 GARDTM<=1 K
Masonry up to 1,000 SF
B
(each)
1 BCONSTAXR
Construction Tax Res
(new detachedgarage)
PATIO'S OPEN
1R3SFDADD OR
IR3SFDREM
1PATIOWOOD
Wood Frame up to 300
B
SF
1 PATIOMETAL
Metal Frame up to 300
B
SF
1 PATIOOTHER
Other Frame up to 300 SF
B
PATIO'S CLOSED
IR3SFDADD OR
& SUN ROOMS
IR3SFDREM
1PATIOENCLW
Enclosed Wood up to 300
B
SF
1 PATIOENCLM
Enclosed Metal up to 300
B
SF
1 PATIOENCLO
Other Enclosed Patio up
B
to 300 SF
1 COVPORCH
Porch Covered -Each
B
(Each)
REMODELS
IR3SFDREM
1REMRESKIT
Kitchen Remodel up to
B
(Deduct'T'for ea plan
300 SF
check
1 REMRESBAT
Bath Remodel up to 300
B
64
SF
1 REMREOTH
Other Remodel up to 300
B
66
SF
CITY OF CUPERTINO
ADDITON/REMODEL
FEE SCHEDULE
Quantity
Sq Ft
Fee ID
Fee Description
Fee Group
Permit Type
1 REMRES2
Remodel Residential
Greater than 1000 sq ft
B
1 REMRES3
Remodel Residential
Greater than 2500 sq ft.
B
1REROOFRES
Residential Re -roof Each
100 SF
B
REMODEL PLNCK
ISTPLNCK (1-3 for
remodel)
Standard Plan Check
B
NOT FOR OVER THE
COUNTER PLAN CKS.
WINDOW/SLIDING
1R3SFDREM
GLASS DOOR
1 WINREP
Replacement windows
(ea 8 windows)
B
1 WINNEWNSTR
New Window (non-
structural)
B
1 WINMEWSTR
New Window (Structural
Shear Wall/Masonry)
B
1 WINBAYSTR
Bay Window (Structural)
B
SKYLIGHTS
1R3SFDREM
1 SKYL<10 SF
Skylight less than 10 sf
B
1 SKYL>1 OSF
Skylight greater than 10
sf or structural
B
1STAIRS
Stairs -first flight/ea addt'l
B
1 EPERMITFEE
Electrical Permit Fee
E
1 MPERMITFEE
Mechanical Permit Fee
M
1PPERMITFEE
Plumbing Permit Fee
P
1 ELCPLNCK
Stand Alone Electric Pln
Ck (hourly)
E
CITY OF CUPERTINO
ADDITON/REMODEL
FEE SCHEDULE
Quantity
Sq Ft
Fee ID
Fee Description
Fee Group
Permit Type
1 MECPLNCK
Stand Alone Mechanical
Pln Ck (hourly
M
1 PLMPLNCK
Stand Alone Plumbing
Pln Ck (hourly)
P
1 BCBSC
Cal Bldg Standards
Commission Fee
B
ALL PERMIT TYPES
1BSEISMICRE
Seismic Residential
B
1 TRAVDOC
Travel & Documentation
B
1BUSLIC
Business License
B
Plan Review Process Work Book Page -12-Revised 3/25/08
Green Building Plan Check
Index of Green Building
Points/Categories
A.
Category
Example of an Index or Table of Green
Plan Sheet or Page
Points
Building Points Categories that must be
shown and referenced on the Project
Plans See below
77"" `+c.,N ..�.nK
.iiv .. a �� .. ._. _, ... ' 'Ry _ .fit _ :,.
�.
k
.� "A a.� :.i.:. 4-'
M**0rn',des;-;
B.
Site
9.
Install H.E. Irrigation, (details/spec)'
L-1
2 points
11.
Permeable Paving, Note
L-1
2 points
C.
Foundation
1.
Use 15 % Flyash Concrete, (note)
S-1
5 points
D.
Structural
3.
Uses Wood I -Joist, (See Spec.)
S-2
2 points
5.
Use Truss with heels, (detail)
S-2
2 points
6.
B. OSB Sheathing, detail
S-2
2 points
E.
Ext. Finish
1.
Composite Decking, (Note/Spec.)
A-3
2 points
4.
B. Fiber Cement Siding, (Note/Spec.
A-4
2 points
F.
Plumbing
1.
Insulate all H.W. pipes, (Note/Spec.)
P-1
2 points
5.
Tankless W.H., (Note/Spec.)
A-2
2 points
11.
A 2500 Gal. Tank, (Note/Spec
L-1
10 Points
G.
Electrical
4.
E. Ceiling Fans, (Note/Spec.)
A-3
4 points
H.
Appliances
1.
Energy Star Dishwasher, (Note/Spec.)
A-3
1 point
3.
Energy Star Refrigerator, (Note/Spec.
A-3
1 point
P.
Other
1.
List Green Features on Plans
A-1
1 point
QAI _,,;,x,11
TOTAL POINTSI
40 points
Plan Review Process Work Book Page -12-Revised 3/25/08
if
Green Points Rating System for Remodeling Projects
Due to the diversity of remodeling project types, assigning a 'total points' value to a project to be considered environmentally friendly is
not feasible. However, 25 measures have been highlighted to signify that every effort should be made to incorporate them into your
projects. These items have been chosen based upon their impact on the environment and the health of the home in coordination with
ease of implementation and relative low cost. These measures can be used as a starting point for 'greening' your project.
A. Site
1. Recycle Job Site Construction & Demolition Waste
65% =1 point; 75% = 2 points; 80% = 4 points
2. Salvage Reusable Building Materials
3. Remodel for Mixed Use, Adaptive Reuse, and
Historic Preservation
4. Protect Native Soil
5. Minimize Disruption of Existing Plants & Trees
6. Implement Construction Site Stormwater Practices
7. Protect Water Quality with Landscape Design
8. Design Resource-Efficiant landscapes and Gardens
9. Reuse Materials/Use Recycled Content Materials
for Landscape Areas
10. Install High -Efficiency Irrigation Systems
11. Provide for On -Site Water Catchment / Retention
B. Foundation
1. Incorporate Recycled Flyash in Concrete
25% Recycled Flyash = 2 points; Add 1 point for every 10%
increase of flyash, up to 5 points
2. Use Recycled Content Aggregate
3. Insulate Foundation/Slab before backfill
C. Structural Frame
1. Substitute Slid Sawn Lumber with Engineered Lumber
2. Use FSC Certified Wood for framing
(For every 10% of FSC lumber used = 2 points, up to 10)
3. Use Wood I -Joists for Floors and Ceilings
4. Use Web Floor Trusses
5. Design Energy Heels on Trusses 6' or more
6. Use Finger -Jointed Studs for Vertical Applications
7. Use Engineered Studs for Vertical Applications
B. Use Recycled Content Steel Studs for Interior Framing
9. Use Structural Insulated Panels (SIPS)
a. Floors
b. Wall
c. Roof
10. Apply Advanced Framing Techniques
11. Use Reclaimed Lumber for Non Structural Applications
12. Use OSB
a. Subfloors
b. Sheathing
up to 4 Resource
4 Resource pts y=
4 Resource pts y=yes
2 Resource pts y=yes
1 Resource pt y=yes
2 Resource pts y=yes
2 Resource pts y=yes
4 Resource pts y=yes
2 Resource pts y=yes
2 Resource pts y=yes
2 Resource pts y=yes
up to 5 Resource pts
2 Resource pts
y=yes
3 Energy pts
y=yes
3 Resource pts
y=yes
up to 10 Resource pts.
2 Resource pts
y=yes
2 Resource pts
y=yes
2 Energy pts
y=yes
2 Resource pts
y=yes
2 Resource pts
y=yes
2 Resource pts
y=yes
3 Energy pts
y=yes
3 Energy pts
y=yes
3 Energy pts
y=yes
4 Resource pts
y=yes
3 Resource pts
y=yes
1 Resource pt
y=yes
1 Resource pt
y=yes
C
0
0
0
r
0
0
0
0
0
1. Use Sustainable Decking Materials
a. Recycled content
3 Resource pts
y --yes
b. FSC Certified Wood
3 Resource pts
y=yes
2. Use Treated Wood That Does Not Contain Chromium./Arsenic
1 IAQ/Health pt
y=yes
3. Install House Wrap under Siding
1 IAQ/Health pt
y=yes
4. Use Fiber -Cement Siding Materials
1 Resource pt
y=yes
E. Plumbing
Up to 4 Energy pts.
1. Install Water Heater Jacket
1 Energy pt y=ye:
2. insulate Hot a -)d Cold Water Pipes
2 Energy pts y=ye:
3. Retrofit all Faucets and Showerheads with Flow Reducers
pts.
a. Faucets (1 point each, up to 2 points)
Up to 2 Resource pts
b. Showerheads (1 point each, up to 2 points)
Up to 2 Resource pts
4. Replace Toilest with Ultra -Low Flush Toilets
(1 point each, up to 3 points)
Up to 3 Resource pts
5. Install Chlorine Filter on Showerhead
1 IAQ/Health pt y=yes
6. Convert Gas to Tankless Water Heater
4 Energy pts y=yes
7. Install Water Filtration Units at Faucets
y=yes
(2 points each, up to 4 points)
Up to 4 IAQ/Health pts
B. Install On -Demand Hot Water Circulation Pump
4 Resource pts y=yes
r-. tiecmcai
1. Install Compact Fluorescent Light Bulbs (CFLs)
(6 bulbs=2 points, 10 bulbs =3 points, 12 bulbs = 4 points)
Up to 4 Energy pts.
2. Install IC -AT Recessed Fixtures with CFLs (1 point each, up to
0
5 points)
Up to 5 Energy
pts.
3. Install Lighting Controls (1 point per fixture, up to 4 points)
Up to 4 Energy
pts.
4. Install High Efficiency Ceiling Fans with CFLs
(1 point each, up to 4 points)
Up to 4 Energy pts.
G. Appliances
1. Install Energy Star Dishwasher
1 Energy pt
y=yes
2. Install Washing Machine with Water and Energy
Conservation Features
1 Energy pt
y=yes
3.Install Energy Star Refrigerator
1 Energy pt
y=yes
4. Install Built-in Recycling Center
3 Resource pts
y=yes
H. Insulation
1. Upgrade Insulation to Exceed Title 24 Requirements
a. Walls
2 Energy pts
y=yes
b. Ceilings
2 Energy pts
y=yes
2. Install Floor Insulation over Crawl Space
4 Energy pts
y=yes
3. Install Recycled -Content, Fiberglass Insulation with
No Added Formaldehyde
3 IAQ/Health pts
y=yes
4. Use Advanced Infiltration Reduction Practices
2 Energy pts
y=yes
5. Use Cellulose Insulation
a. Walls
4 Resource pts
y=yes
b. Ceilings
4 Resource pts
y=yes
6. Alternative Insulation Products (Cotton, spray -foam)
a. Walls
4 Resource pts
y=yes
o. Ueilings
4 Resource pts
y=yes
INPUT ResDUMe5 .Energy IAQIHeakfi
D
If
0
0
0
0
0
0
I
91
0
0
0
i. vvinoows
2 Energy pts
y=yes
1. Install Energy -Efficient Windows
2 Energy pts
y=yes
a. Double -Paned
1 Energy pt
y=yes
b. Low -Emissivity (Low -E)
2 Energy pts
y=yes
c. Low. Conductivity Frames
2 Energy pts
y=yes
2. Install Low Heat Transmission Glazing
1 Energy pt
y=yes
J. Heating Ventilation and Air Conditioning
2 Energy pts
y=yes
1. Use Duct Mastic on AN OW Joints
2 Energy pts
y=yes
2. Install Ductwork within Conditioned Space
3 Energy pts
y=yes
3. Vent Range Hood to the Outside
1 IAQ/Health pt
y=yes
4. Clean all Ducts Before Occupancy
2 IAQ/Health pts
y=yes
5. Install Solar Attic Fan
2 Energy pts
y=yes
6. Install Attic Ventilation Systems
1 Energy pt
y=yes
7. Install Whole House Fan
4 Energy pts
y=yes
B. Install Sealed Combustion Units
3 IAQ/Health pts
y=yes
a. Furnaces
3 IAQ/Health pts
y --yes
b. Water Heaters
3 IAQ/Health pts
y=yes
9. Replace Wall -Mounted Electric and Gas Heaters with
Through -the -Wall Heat Pumps
3 Energy pts
y=yes
10. Install 13 SEER/11 EER or higher AC with a TXV
3 Energy pts
y=yes
11. Install AC with Non -HCFC Refrigerants
2 Resource pts
y=yes
12. Install 90% Annual Fuel Utilization Efficiency (AFUE) Furnace
2 Energy pts
y=yes
13. Retrofit Wood Burning Fireplaces
a. Install EPA certified wood stoves/inserts
1 IAQ/Health pt
y=yes
b. Install/Replace Dampers
1 Energy pt
y=yes
c. Install Airtight Doors
1 Energy pt
y=yes
14. Install Zoned, Hydronic Radiant Heating
3 Energy pts
y=yes
15. Install High Efficiency Filter
4 IAQ/Health pts
y=yes
16. Install Heat Recovery Ventilation Unit (HRV)
5 IAQ/Health pts
y=yes
17. Install Separate Garage Exhaust Fan
3 IAQ/Health pts
y=yes
K. Renewable Energy and Roofing
1. Pre -Plumb for Solar Water Heating 4 Energy pts y=
2. Install Solar Water Heating System 10 Energy pts y=
3. Pre -Wire for Future Photovoltaic (PV) Installation 4 Energy pts y=
4. Install Photovoltaic (PV) System
(1.2 kw = 6 points, 2.4 kw =12 points, 3.6 kw =1 B points) Up to 18 Energy
6. Select Safe and Durable Roofing Materials 1 Resource pt y=
7. Install Radiant Barrier 3 Energy pts y=
L. Natural Heating and Cooling
1. Incorporate Passive Solar Heating 5 Energy pts y=yes
2. Install Overhangs or Awnings over South Facing Windows 3 Energy pts y=yes
3. Plant Deciduous Trees on the West and South Sides 3 Energy pts y=yes
1. Use Low/No-VOC Paint
2. Use Low VOC, Water -Based Wood Finishes
3. Use Low/No VOC Adhesives
4. Use Salvaged Materials for Interior Finishes
5. Use Engineered Sheet Goods with no added Urea
Formaldehyde
6. Use Exterior Grade Plywood for Interior Uses
7. Seal all Exposed Particleboard or MDF
8. Use FSC Certified Materials for Interior Finish
9. Use Finger -Jointed or Recycled -Content Trim
10. Install Whole House Vacuum System
N. Flooring
1. Select FSC Certified Wood Flooring
2. Use Rapidly Renewable Flooring Materials
3. Use Recycled Content Ceramic Tiles
4. Install Natural Linoleum in Place of Vinyl
5. Use Exposed Concrete as Finished Floor
6. Install Recycled Content Carpet with Low VOCs
Total Points Available:
Total Points Project Received:
1 IAQ/Health pts
y=yes
21AQ/Health pts
y=yes
31AQ/Health pts
y=yes
3 Resource pts
y=yes
61AQ/Health pts
y=yes
1 IAQ/Health pts
y=yes
4IAQ/Health pts
y=yes
4 Resource pts
y=yes
1 Resource pts
y=yes
3 IAQ/Health pts
y=yes
8 Resource pts
y=yes
4 Resource pts
y=yes
4 Resource pts
y=yes
5 IAQ/Health pts
y=yes
4 Resource pts
y=yes
4 Resource pts
y=yes
1401 130 57
001 UO 6 0
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CITY Of
CUPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
JOB ADDRESS:
((�Zoo 'E-� i u �V54A
PERMIT #
b D/ S CD
OWNER'S NAME: b
PHONE #
GENERAL CONTRACTOR:
FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
Owner/Contra for Signature
(��(2Ic-)�
Date
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
Owner/Contra for Signature
(��(2Ic-)�
Date