09100155-EXPIREDI CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10200 MILLER AVE BLDG F I CONTRACTOR: TBD - TO BE DETERMINED I PERMIT NO: 09100155
OWNER'S NAME: RODNEY BERGMAN I I DATE ISSUED: 10/22/2009
OWNER'S PHONE: 8018152469 1 , PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
License Class
Contractor
Lic. #
Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
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
permit is issued.
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
upon the above mentioned property for inspection purposes. (We) agree to save
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
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature
lam
OWNER -BUILDER DECLARATION
/( hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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 & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
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
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
permit is issued.
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 Worker's
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
forthwith comply with such provisions or this permit shall be deemed revoked.
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
upon the above mentioned property for inspection purposes. (We) agree to save
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 co ply
with all non-poYmt �Cf�rcegulations per the Cu ertino Municipal Code, tion
9.18. / ' j
Signature
BUILDING PERMIT INFO: BLDG r ELECT r— PLUMB r
MECH r RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: CREATE AN 8SQFT SPACE FOR A
WASHERIDRYER FROM AN
EXISTING CLOSET
Sq. Ft Floor Area:
Valuation: $9600
APN Number: 37503005.BLDGF I Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued = Date: /U---Lq-rf
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health A Safety Code, Sections 25505, 25533, and 25534.
Date: ✓`"� f
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
M -
CITY OF
CUPERTINO
CITY OF CUPERTINO
ADDITION/REMODEL
PERMIT APPLICATION FORM
APN # L -b G F
Date: D 22 O
Is a 2" unit being added? Yes ❑ No If yes, please fill out the permit application for 2" unit.
Building Address: ) N1 LA, _-tN,\/S7 'o
Mailing Address (if different from building addret�,,__
Owner's N � � � /
Phone , eels a L
Contra
Phone #:O a
Fax #:
Contractor License #: C72�
Cupertino Business License #:
Contact:� f-
M�T r �
Phone #: �jg
Fax #:
Building Permit Info:
Bldg. & Elect. lig Plumb. Mech. ❑ Hillside ❑
Job Description:
Addition -What is being added?(Be Specific):
What is being rem�`Jo(ddeled (not including addition)? a"� � "� Po (j 3 -T:-- A? rPWOE7 lz�
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:
P
I -A, 1-B ❑ II/III/V-A ❑ IVIII B, IV -HT, V
'_�3
Valuation: goO'c'
Please check this box if the project is a
second -story addition ❑
Project Size: Express E Standard ❑ Large ❑ Major ❑
Please complete relevant portion of the Green Building
Checklist & attach it to the application or if applicable,
Green Building Points Achieved: U
include in plan set & the sheet index.
***For Office Use Only***
Over -the -Counter ❑
Revised 07/06/09
CITY OF CUPERTINO
ADDITON/REMODEL
FEE SCHEDULE
Quantity
Fee ID
Fee Description
Fee Group
Permit Type
Sq Ft
DECKS
1R3SFDADD OR
1R3SFDREM
1DECKWOOD
Deck (Wood) -Each
B
(Each)
1 DECKRAIL
Deck Railing -Each
B
(Each)
GARAGES
1R3SFDADD 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 detached garage)
PATIO'S OPEN
1R3SFDADD OR
1R3SFDREM
1 PATIOWOOD
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
1R3SFDADD OR
& SUN ROOMS
1R3SFDREM
1PATIOENCLW
Enclosed Wood up to 300
B
SF
1PATIOENCLM
Enclosed Metal up to 300
B
SF
1PATIOENCLO
Other Enclosed Patio up
B
to 300 SF
1COVPORCH
Porch Covered -Each
B
(Each)
REMODELS
1R3SFDREM
1REMRESKIT
Kitchen Remodel up to
B
(Deduct'T'for ea plan
300 SF
check
1REMRESBAT
Bath Remodel up to 300
B
64
SF
/�
1REMREOTH
Other Remodel up to 300
SF
B
66
CITY OF CUPERTINO
ADDITON/REMODEL
FEE SCHEDULE
Quantity
Sq Ft
Fee ID
Fee Description
Fee Group
Permit Type
1MECPLNCK
Stand Alone Mechanical
Pln Ck (hourly
M
IPLMPLNCK
Stand Alone Plumbing
Pln Ck(hourly)
P
1BCBSC
Cal Bldg Standards
Commission Fee
B
ALL PERMIT TYPES
1BSEISMICRE
Seismic Residential
B
1TRAVD0C
Travel & Documentation
B
IBUSLIC
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
i _ EW.Mr w
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
TOTAL POINTS,40
points
Plan Review Process Work Book Page -12-Revised 3/25/08
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.
1. Recycle Job Site Construction & Demolition Waste
65% =1 point; 75% = 2 points; BO% = 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
B. Design Resource -Efficient 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 Flyashin 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 Solid 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 pts
4 Resource pts y=yes
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
up to 10
2 Resource
2 Resource
2 Energy p
2 Resource
2 Resource
2 Resource
3 Energy p
3 Energy p
3 Energy p
4 Resource
3 Resource
1 Resource
1 Resource
pts y=yes
3esource pts.
pts y=yes
pts y=yes
s y=yes
pts y=yes
pts y=yes
pts y=yes
s y=yes
s y=yes
s y=yes
pts y=yes
pts y=yes
pt y=yes
pt y=yes
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
1
1. Install Energy -Efficient Windows
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 Wastic on All Duct 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=yes
2. Install Solar Water Heating System 10 Energy pts y=yes
3. Pre -Wire for Future Photovoltaic (PV) Installation 4 Energy pts y=yes
4. Install Photovoltaic (PV) System
(1.2 kw = 6 points, 2.4 kw =12 points, 3.6 kw =18 points) Up to 18 Energy pts
6. Select Safe and Durable Roofing Materials 1 Resource pt y=yes
7. Install Raoiant Barrier 3 Energy pts y=yes
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
J
CITY of
CUPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
00-00 j`i1 t L t-Ef2. AV 6 F
PERMIT #
O/ a d,
OWNER'S NAME:
PHONE # ez'vP-
GENERAL CONTRACTOR:
FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
� � Z
O ner ntra r Signature Date
21
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
� � Z
O ner ntra r Signature Date