09100201CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10181 STERN AVE
CONTRACTOR: GUILLEN CONSTRUCTION
PERMIT NO: 09100201
CO.
OWNER'S NAME: TOM SIDLAUSKAS
10660 CULBERTSON DR
DATE ISSUED: 10/29/2009
. .vNER'S PHONE: 4089739033
CUPERTINO, CA 95014
PHONE NO: (408)725-0782
❑ LICENSED CONTRACTOR'S DECLARATIONF
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lie. #
MECH f— RESIDENTIAL f— COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: REMOVE STUCO AND REPLACE PLYWOOD,
(commencing with Section 7000) of Division 3 of the Business & Professions
DRYROT
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
1 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
Sq. Ft Floor Area:
Valuation: $5000
performance of the work for which this permit is issued.
1 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: 37511065.00
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
PERMIT EXPIRES IF. WORK IS NOT STARTED
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
180 DAYS FROM LAST CALLED INSPECTION.
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 pe the Cupertino Municipal Code, Section
Issued Date:
9.18.
S; -nature Date
RE -ROOFS:
OWNER -BUILDER DECLARATION
All roofs shall be inspected prior to any roofing material being installed. If a roof is
rlher-eby
installed without first obtaining an inspection, I agree to remove all new materials for
affirm that I am exempt from the Contractor's License Law for one of
inspection.
the following two reasons:
1, as owner of the property, or my employees with wages as their sole compensation,
Signature of Applicant: Date:
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
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self -insure for Worker's
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
Compensation, as provided for by Section 3700 of the Labor Code, for the
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
performance of the work for which this permit is issued.
Safety Code, Section 25532(a) should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance, as provided for by
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
Section 3700 of the Labor Code, for the performance of the work for which this
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued.
Health & Safety Code, Sections 25505, 25533, and 25534.
1 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
Ov�nkr,,or auth ent:
Compensation laws of California. If, after making this certificate of exemption, I
`Date:_Z rCx '2'-7
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.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION
for which this permit is issued (Sec. 3097, Civ C.)
I certify that I have read this application and state that the above information is
Lender's Name
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
Lender's Address
I' the above mentioned property for inspection purposes. (We) agree to save
nify and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
I understand my plans shall be used as public records.
with all non -point source regulations per - pertino Municipal Code, Section
9.18. ""�
Licensed Professional
r-- Date
Signature
3 ITEMS OF 3
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN 37511065.00
DATE ISSUED.......: 10/29/2009
RECEIPT #.........: BS000009068
REFERENCE ID # ...: 09100201
SITE ADDRESS .....: 10181 STERN AVE
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......
OWNER TOM SIDLAUSKAS
ADDRESS 10181 STERN AVE
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
OPERATOR: patg
COPY # : 1
RECEIVED FROM ....: TOM SIDLAUSKAS
CONTRACTOR NOEL GUILLEN LIC # 28522
COMPANY GUILLEN CONSTRUCTION CO.
ADDRESS 10660 CULBERTSON DR
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
TELEPHONE ........: (408)725-0782
FEE ID UNIT
QUANTITY
AMOUNT PD -TO -DT
THIS REC
----------
NEW BAL
----------
-----------------------
1BCBSC VALUATION
----------
5,000.00
--------------------
1.00
0.00
1.00
0.00
1BSEISMICR VALUATION
5,000.00
0.50
0.00
0.50
0.00
1STUCOAPP SQ FEET
1.00
443.00
----------
0.00
443.00
----------
0.00
----------
TOTAL PERMIT
----------
444.50
0.00
444.50
0.00
METHOD OF PAYMENT
AMOUNT
REFERENCE
--------------------
NUMBER
----------------- ---------------
CREDIT CARD
444.50
VISA
---------------
TOTAL RECEIPT
444.50
CITY OF
CUPERTINO
03"�-7- f I
CITY OF CUPERTINO
GENERAL BUILDING
PERMIT APPLICATION FORM
OCp15.00
,09 � bA,01
APNDate:
Zc7-
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Building Address:
Mailing Address (if different from building address):
Are Hazardous Materials being used as part
of this project? Yes 0 No;U
HOA:(Exterior work only) Yes ❑ No
If yes, provide letter from HOA
Owner's Name
` S
Phone #:
(, v
Contractor: /
Phone:
Civ re P1 (_ ov7 vLc t'c�rz
C
Fax:
Contractor License #: 6 51 CS—1 7,
Cupertino Business License #:
Contact:
Phone:
Fax:
Residential IR Commercial
Job Description: y�P��e j?✓� y
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Building Permit Info:
Bldg KI Elect ❑
Plumb ❑ Mech ❑
Type of Construction (Usage Class):
Occupancy Type:
1-A, 1-B,' II/III/V-A ❑ II/III B, IV -HT, V -B
(9 l3
Valuation:
Square Footage:
Old
Project Size: Express ❑ Standard
Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set & the sheet index.
Points Achieved:
For help, contact Build it Green at www.buildit reen.or
Revised 07/14/09
S'62W
CITY OF
CUPEI,TINO
CITY OF CUPERTINO
GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf
Fee ID
Fee Description
Fee
Group
Permit Type
1GENRES or
1GENCOM
. -
1STUCOAP
Stucco Applications (up to 400 sf)
additional stucco application
B
1 WINREP
Replacement windows/sliding glass
door (ea 8 windows)
B
1 WINMEWSTR
New Window -structural shear
wall/masonry (includes plan ck fee)
B
1 EPERMITFEE
Electrical Permit Fee
E
1MPERMITFEE
Mechanical Permit Fee
M
1PPERMITFEE
Plumbing Permit Fee
P
IELCPLNCK
Stand Alone Electric Pln Ck (hourly)
E
1 MECPLNCK
Stand Alone Mechanical Pln Ck (hrly)
M
1PLMBLNCK
Stand Alone Plumbing Pln Ck (hrly)
P
1 STPLNCK-(3 Hr Min
when not over counter)
Standard Plan Check (when no E/M/P)
hourly -stand alone
B
1BCBSC
Cal Bldg Standards Commission Fee
B
ALL PERMIT
TYPES
'
1BSEISMICR
Seismic Residential
B
1BSEISMICO
Seismic Commercial
B
1 TRAVDOC
Travel & Documentation
B
1 BUSLIC
Business License
B
5 of 5
1. lyse Low/No-OC 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
S. Use Exterior Grade Plyr000d for Interior Uses
7..Sad Iael iitiolaboard,or OF
B. Use FSC Certified Materials for Interior Finish
9. Use Finger -Jointed or Recycled -Content Trim
10. Install Whole House Vacuum System
N. Fiooring
1. Select FSC Certified Wood Flooring
2. Use 13apidfy Renewable Flooring Materials
3. Use Recycled Content Ceramic Tiles
4. Install Natural Linoleum in Place of Vinyl .
5. Use Exposed Concrete as Finished Floor
S. 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
3IAQ/Health pts
y=yes
3 Resource pts
y=yes
61AQ/Health pts y=yes
1 IAQ/Health pts y=yes
4 Resource pts y=yes
1 Resource pts y=yes
3 [AD/Health pts y=yes
B 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
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CITY OF
XPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
PERMIT #
OWNER'S NAME:
PHONE #
GENERAL CONTRACTOR: n
FAX #
I am not using any subcontractors: D b�
gnature Date
Please check am)licable subcontractors and complete the following information:
/Contractor S)
Z�A=1&1410-11
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
/Contractor S)
Z�A=1&1410-11