09100152-EXPIREDI CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 10200 MILLER AVE BLDG L I CONTRACTOR: TBD - TO BE DETERMINED I PERMIT NO: 09100152
OWNER'S NAME: RODNEY BERGMAN I I DATE ISSUED: 10/22/2009
OWNER'S PHONE: 8018152469 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class
Contractor
Lic. #
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.
Date
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1, 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)
1, as owner of the property, am exclusively contracting withlicensed 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, l 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 comply
with all non -point Arra regulations per the Cupertino Municipal Code, Section
9.18. H ,/ i _-
Signature
MECH r RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: CREATING AN 8SQFT SPACE FOR
WASHER/DRYER FROM AN
EXISTING CLOSET
Sq. Ft Floor Area:
Valuation: $6400
APN Number: 37503005.BLDGL I Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
C
Issued by: �- Date. Z Z
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 & Safety Code, Sections 25505, 25533, and 25534.
ON, n r o ' gent: i
Date: ` b � (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 Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
V /7 '2 [F I Licensed Professional
CITY OF
CUPERTINO
CITY OF CUPERTINO
ADDITION/REMODEL
PERMIT APPLICATION FORM
09t oul SZ
APN #
Date: 10 • �/� .`i!�)
Is a 2" unit being added? Yes ❑ No;K If yes, please fill out the permit application for 2" unit.
Building Address: lb:7,oa f -IU 6F YWV . -4 /
(/
Mailing Address (if different from building address):
Owner's Name:
p,00 N C -y 13 &/z
Phone #
dol ( " �-
Contractor:
Phone #: ' �1p q —I -I- 7�2,
Fax#:
Contractor License #: g6 a a 7
Cupertino Business License #:
Contact:
Phone #: "C— ra6 i - t 2'-7 2_
VVN6-i_-T 1 r i S0"s-
Fax #:
Building Permit Info:
Bldg.k]/ Elect. — - Plumb. Mech. E --- Hillside ❑
Job Description:
Addition -What is being added?(Be Specific):
What is being remodeled (not including addition)? Gfzo���' #,V 6 s .r—, - ,rm
WP ** (Vp�t�l f -SW 14") _kA111(1VJ& C -10$07 -
Remodel Includes Re -Roof. Yes ❑ No If yes list number of squares
Remodel Includes Structural: Yes F-1No�
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:
1-A, 1-B ❑ II/III/V-A ❑ II/VI B, IV -HT, V -B
Valuation:
Please check Nis box if the project is a
second -story addition ❑
Project Size: Express ❑ 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
1
(at
CITY OF
CUPEkTINO
CITY OF CUPERTINO
ADDITION/REMODEL
FEE SCHEDULE
Quantity
Sq Ft
Fee ID
Fee Description
Fee Group
Permit Type
ADDITIONS
IR3SFDADD
1PLLONGRNGR
Long Range
Planning/Residential
PL
lR31NSP
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
1R3HREINSP
Dwellings Hillside
Repeat Inspection
B
1R3HREPLNC
Dwellings Hillside
Repeat Plan Check
B
1 R3ALTINSP
Dwellings Alternate
Materials Inspection
B
1 R3ALTPLNC
Dwellings Alternate
Materials Plan Check
B
1PCESS
Cesspool
P
1PPRSEWG
Ea. Private Sewage
Disposal System
P
1 PRSEWER
Sewers
P
1BPSPRINK
Lawn Sprinkler/Backflow
P
1BPWSVCS
Main Water Service
P
1BCBSC
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
1R3SFDADD OR
DETACHED
1R3SFDREM
1 GARDTW<=1 K
Wood Frame up to
B
1,000 SF (each)
1GARDTM<=1K
Masonry up to 1,000 SF
B
(each)
1 BCONSTAXR
Construction Tax Res
(new detachedgarage)
PATIO'S OPEN
1R3SFDADD OR
1R3SFDREM
1 PATIOWOOD
Wood Frame up to 300
B
SF
1PATIOMETAL
Metal Frame up to 300
B
SF
1 PATIOOTHER
Other Frame up to 300 SF
B
PATIO'S CLOSED
1R3SFDADD OR
& SUN ROOMS
1R3SFDREM
1 PATIOENCLW
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
1R3SFDREM
1 REMRESKIT
Kitchen Remodel up to
B
(Deduct "$"for ea plan
300 SF
check
1 REMRESBAT
Bath Remodel up to 300
B
"
SF
1 REMREOTH
Other Remodel up to 300
B
SF
CITY OF CUPERTINO
ADDITON/REMODEL
FEE SCHEDULE
Quantity
Sq Ft
Fee ID
Fee Description
Fee Group
Permit Type
1REMRES2
Remodel Residential
Greater than 1000 sq ft
B
1REMRES3
Remodel Residential
Greater than 2500 sq ft.
B
1REROOFRES
Residential Re -roof Each
100 SF
B
REMODEL PLNCK
1STPLNCK (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
1SKYL>10SF
Skylight greater than 10
sf or structural
B
1STAIRS
Stairs -first flight/ea addt'1
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
ITRAVDOC
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
•k_ �: �
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
`-O
�...,.Rv� . ']
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.
A. Site
1. Recycle Job Site Construction & Demolition Waste
3 Resource pts
y=ye:
65% = 1 point; 75110 = 2 points; 801,� = 4 points
up to 4 Resource pts
2. Salvage Reusable Building Materials
4 Resource pts
y=yes
3. Remodel for Mixed Use, Adaptive Reuse, and
2 Resource pts
y=ye:
Historic Preservation
4 Resource pts
y=yes
4. Protect Native Soil
2 Resource pts
y=yes
5. Minimize Disruption of Existing Plants & Trees
1 Resource pt
y=yes
6. Implement Construction Site Stormwater Practices
2 Resource pts
y=yes
7. Protect Water Quality with Landscape Design
2 Resource pts
y=yes
8. De8l9n Aesourae-Efficient Landscapes and Gardens
4 Resource pts
y=yes
9. Reuse Materials/Use Recycled Content Materials
3 Energy pts
y=yeE
for Landscape Areas
2 Resource pts
y=yes
10. Install High -Efficiency Irrigation Systems
2 Resource pts
y=yes
11. Provide for On -Site Water Catchment / Retention
2 Resource pts
y --yes
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 up to 5 Resource pts
2. Use Recycled Content Aggregate 2 Resource pts y=yes
3. Insulate Foundation/Slab before backfill 3 Energy pts Y_—Yes
C. Structural Frame
1. Substitute Solid Sawn Lumber with Engineered Lumber
3 Resource pts
y=ye:
2. Use FSC Certified Wood for framing
(For every 10% of FSC lumber used = 2 points, up to 10)
up to 10 Resource pts
3. Use Wood I -Joists for Floors and Ceilings
2 Resource pts
y=ye:
4. Use Web Floor Trusses
2 Resource pts
y=ye:
5. Design Energy Heels on Trusses 6" or more
2 Energy pts
y=yeE
6. Use Finger -Jointed Studs for Vertical Applications
2 Resource pts
y=yec
7. Use Engineered Studs for Vertical Applications
2 Resource pts
y=yec
8. Use Recycled Content Steel Studs for Interior Framing
2 Resource pts
y=yec
9. Use Structural Insulated Panels (SIPS)
a. Floors
3 Energy pts
y=yeE
b. Wall
3 Energy pts
y=yeE
c. Roof
3 Energy pts
y=yeE
10. Apply Advanced Framing Techniques
4 Resource pts
y—yeE
11. Use Reclaimed Lumber for Non Structural Applications
3 Resource pts
y=yeE
iz Use OSB
a. SWADOM
1 Resource pt
y=yeE
b• Sho ing
1 Resource pt
y=yeE
0
0
0
0
0
6
0
0
0
II—
1 0. Exterior Finish
INPUT ReSDUTMS Energy JADli ealth
1. Use Sustainable Decking Materials
�
1. Install Water Heater Jacket
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
�
1. Install Water Heater Jacket
1 Energy pt y=ye;
2. Insulate Hot and Cold Water Pipes
2 Energy pts y=ye:
3. Retrofit all Faucets and Showerheads with Flow Reducers
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
Up to 4 Energy
(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
(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-. trecmcai
_-
1. Install Compact Fluorescent Light Bulbs (CFLs)
�
0
(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 poi -it each, up to
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
n. c;euings
4 Resource pts
y=yes
X
�
0
�
0
0
of
X
�
0
�
X
0
I
91
0
0
I. 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
1. Use Duct Mastic 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
5 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 Radiant 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
1. Use Low/No-VOC Paint
1 IAQ/Health pts
y=yes
2. U_ e Low VOC, Water -Based Wood Finishes
2 IAQ/Health pts
y=yes
3. Use Low/No VOC Adhesives
3 IAQ/Health pts
y=yes
4. Use Salvaged Miaterials for Interior Finishes
3 Resource pts
y=yes
5. Use Engineered Sheet Goods with no added Urea
4 Resource pts
y=yes
Formaldehyde
61AQ/Health pts
y=yes
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
B. Use FSC Certified Materials for Interior Finish
4 Resource pts
y=yes
9. Use Finger -Jointed or Recycled -Content Trim
1 Resource pts
y=yes
10. Install Whole House Vacuum System
3 IAQ/Health pts
y=yes
N. Flooring
1. Select FSC Certified Wood Flooring
B Resource pts
y=yes
2. Use Rapidly Renewable Flooring Materials
4 Resource pts
y=yes
3. Use Recycled Content Ceramic Tiles
4 Resource pts
y=yes
4. Install Natural Linoleum in Place of Vinyl
5 IAQ/Health pts
y=yes
5. Use Exposed Concrete as Finished Floor
4 Resource pts
y=yes
6. Install Recycled Content Carpet with Low VOCs
4 Resource pts
y=yes
Total Points Available:
Total Points Project Received:
I
I
1401 130 57
,\l 0 01 0 01 0
G:datalprogslgreenbuildngguidelineslremodelers/grnenpointsfina1212.D4protectedxls
CITY OF
CUPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
PERMIT #
S�2
OWNER'S NAME:
PHONE # 40t
GENERAL CONTRACTOR:
FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
L� t l 4 Z
Owner/Co actor gnature 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
Tile
L� t l 4 Z
Owner/Co actor gnature Date