09100053 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10300 WUNDERLICH DR CONTRACTOR:RODRIC HANSELL PERMIT NO:09100053
OWNER'S NAME: RODRIC HANSELL 1405 HARRIET CT DATE ISSUED: 10/07/2009
ER'S PHONE: 4086881778 CAMPBELL,CA 95008 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH f- RESIDENTIAL f- COMMERCIAL
Contractor Date i Cs,
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:A'O6'AMP METER MAIN SERVICE UPGRADE
(commencing with Section 7000)of Division 3 of the Business&Professions REPLACE GARAGE
Code and that my license is in full force and effect. WALL ELECTRICAL REPLACE OUTSIDE CONDUIT
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.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$300
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:37517014.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that 1 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
Dater
Signature Date
OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby 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
the following two reasons: inspection.
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, Signature of Applicant: Date:
Business&Professions Code)
I,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
HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's 1 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. 1 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
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cuperti Municipal Code,Chapter 9.12 and the
1 certify that in the performance of the work for which this permit is issued,l shall Health&Safety Code,Sections 2550 5533,and 25534.
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 Own e or ut r!W AIM-
become
subject to the Worker's Compensation provisions of the Labor Code,I must Date:
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
inify and keep harmless the City of Cupertino against liabilities,judgments,
and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applican nderstands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cu rtino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
D 1:21 Licensed Professional
Signature Date
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY ## 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37517014 .00
DATE ISSUED. . . . . . . : 10/07/2009
RECEIPT #. . . . . . . . . BS000008859
REFERENCE ID # . . . 09100053
SITE ADDRESS . . . . . : 10300 WUNDERLICH DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER RODRIC HANSELL
ADDRESS 1405 HARRIET CT
CITY/STATE/ZIP . . . : CAMPBELL, CA 95008
RECEIVED FROM . . . . : RODRIC G HANSELL
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY RODRIC HANSELL
ADDRESS 1405 HARRIET CT
CITY/STATE/ZIP . . . : CAMPBELL, CA 95008
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 300. 00 1 .00 0 . 00 1 . 00 0 . 00
1BREMMISC FLAT RATE 1 . 00 126 .00 0 .00 126 . 00 0 . 00
1BSEISMICR VALUATION 300 . 00 0 .50 0.00 0 . 50 0 .00
1EPERMITFE FLAT RATE 1. 00 42 . 00 0. 00 42 . 00 0 .00
1ERT<200 UNITS 1. 00 42 . 00 0. 00 42 . 00 0 .00
1TRAVDOC FLAT RATE 1. 00 42 . 00 0 . 00 42 . 00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 253 .50 0 .00 253 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 253 .50 DISCOVER
---------------
TOTAL RECEIPT 253 .50
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(reverse side).
Property Owner's Signature: �"'_-'✓ I }�'' t,j; Date:
Job Address: Permit# D 1 U o O 3
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
605 -�L
CITY OF CUPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN# Date: ,, J
Building Address: _
�►G l '-'
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes No
HOA: Exterior work only) Yes ❑ No If yes, provide letter from HOA
Owner's Name: Phone#: , <- r
Contractor: p Phone:
c` ;_J r.4 (�i� / Fax:
Contractor License
Cupertino Business License#:
Contact: Phone: (1, �`? t 7?Y
*'?c d I� 11 Fax: .7� -- t
Residential 54Commercial El
Job Description: _
�L P�Pc= G A(:�,CAc�i w�i_L_ 1✓C� �c L
9i PLAC-&� 0 OT-S i PP-- C0?-J p v 1 q
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Type of Construction(Usage Class): Occupancy Type:
r
1-A, 1-B ❑ II/III/V-A ❑ 11/111 B, IV-HT, V-B fi F�i�t t ��
Valuation: Square Footage:
Project Size: Express 91�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.builditgreen.org
Revised 07/14/09
CITY OF CUPERTINO
C U
CITY
OF O GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Window-structural shear B
wall/masonry(includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit Fee P
1 ELCPLNCK Stand Alone Electric Pln Ck(hourly) E
1MECPLNCK Stand Alone Mechanical Pln Ck(hrly) M
1PLMBLNCK Stand Alone Plumbing Pln Ck(hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check(when no EMP) B
when not over counter) hourly-stand alone
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel &Documentation B
1BUSLIC Business License B
5 of 5
M.Indoor Air Ouality and Finishes
1.list ioift-VOC �t 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*YQC Adwom 31AQ/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
0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes
-SiW,41 15PrJXF 41AQ/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
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 0
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring 8 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=yesl 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 !
Total Points Available: 1 1401 1301 57
Total Points Project Received: 01 01 0
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