09120096 CITY OF CUPERTIN O BUILDING PERMIT
BUILDING ADDRESS: 18631 BARNHART AVE CONTRACTOR:ALERT PLUMBING PERMIT NO:09120096
OWNER'S NAME: LORAINE HUCK 2530 BERRYESSA RD DATE ISSUED: 12/15/2009
`ER'S PHONE: 4082721423 SAN JOSE,CA 95132 PHONE NO:(408)272-1423
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class '76 Lic. o�,, 6
e MECH RESIDENTIAL COMMERCIAL
Contractor /2 O
1 hereby affirm that I am licensed under t e provisions of Chapter 9 JOB DESCRIPTION:GAS LINE CHANGE THRU HOUSE;GAS METER RELEASE
(commencing with Section 7000)of Division 3 of the Business&Professions REQUIRED
Code and that my license is in full force and effect.
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:$4000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:37526036.01 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 Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which y ccnr gainst said City in of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this it. A iti a applicant understands and will comply
with all non-point so Fee r gu tion e e Cupertino Municipal Code,Section
9.18. Issued
Signature Date 2 S ��
L, OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
1 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 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,sh;uefi,ed
ld I use a ment or devices which emit hazardous air
contaminant b he A ea Air Quality Management District I will
pen-nit is issued. maintain comp n the pe i o 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&Saf ode,S cti 25 5, 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 Owner thorized ag
become subject to the Worker's Compensation provisions of the Labor Code,I must. Date: 1 1. !5 •0
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 inspection purposes.(We)agree to save Lender's Address
it nify p harmless the ty f Cupertino against liabilities,judgments,
i'. .indxpense whic ma ac nr against said City in consequence of the ARCHITECT'S DECLARATION
granting this pe it. dd' y, applicant understands and will comply
with all n -p in s u egul i n per a Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
O� Licensed Professional
Signature - Date
j(I t 2- ci to
CITY OF CUPERTINO
REPIPE/SEWS R/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN# �2 J Date:
12 L D
Building Address:
Owner's Name Phone#:
&VILi ,r 27 Z- /y Z 3
Contractor: Phone#:
T 1 V JJA61 C Fax#: z 0f 272 --27 S Y
Contact: Phone#:
P1(/MiI1-" Fax#:
Contractor License#: 9576762—
Cupertino
S7676ZCupertino Business License#:
Job Description:
Residential [ Commercial ❑
Valuation: e�c7
�D6Z� -.---
Project Size: Express Standard ILP
Large T Major El
Green Building: Please complete relevant portion of the Green Building Checklist& attach it to the
application or if applicable, include in plan set& the sheet index.
Green Building Points:
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCSEWER Commercial building P ICPSS
sewer/sanitary sewer
1 BPREPIPE Commercial re-pipe per fixture P 1CPRP
1PGASCOM Commercial Gas Piping System P
1-4 Outlets
1 BCBSC Cal Bldg Stand�xds Commission B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 01/07/09
CITY OF C UPERTINO
SA4
REPIPE/SEWER`MAIN SERVICE
CITYCUPE(ZTINO FEE SCHEDULE
Quantity Fee ID Fee Descriptior. Fee Permit Type
Group
1BCBSC Cal Bldg Standard:, Commission B ALL PERMIT
Fee TYPES
f 1BSEISMICR Seismic Residential P
1PRSEWER Residential building P 1R-PSS
sewer/sanitary sewer - -
1PRREPIPE Residential re-pipe per fixture P IRP"
1BPWSVCS Water Service P 1CPWS or
1RPWS
1 PPRSEWG Private Sewage Di;;posal System P
1PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
1 BPFIXTURE Plumbing Fixture P
1PGASRES Residential Gas Pi,)ing System P
r 1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
1 PPERMITFEE Plumbing Permit Fee Issuance P
1PLMBLNCK Plumbing Plan Chick P
1PLMBINSP Other Plumbing/gE.s Insp. P
1TRAVDOC Travel & Documentation Fee B
1BUSLIC Business License B
M.Indoor Air Quality and Finishes-
1.LtiLOWN6-roc P4k#. 1 IAQ/Health pts y--yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3.Use l.DallpVOCA 3 IAQ/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 31AQ/Health pts y=yes 0
0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes
7..3e.�dbDfdir 1 IAQ/Health. pts y=yes 0
8.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 r IAQ/Health pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resourcepts y=yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
Total Points Available: 1401 130 57
Total Points Project Received: 01 0 :]0
G:data/progs/greer:)uiidingguidelines/remodelers/greenpointsfinal212.o4protected.xis
Community Development
�y 10300 Torre Avenue
Cupertino CA 95014
fy Telephone(408)777-3228
CITY OF Fax(408)777-3333
-.UPEkTINO
Building Department
JOB ADDRESS: PERMIT#
1 v e 2D
OWNER'S NAME: r PHONE # 0F)27?2.-l41Z 3
GENERAL CONTRACTOR: - b FAX #
I am not using any subcontractors: �2 S
Si,nature Date
Please check applicable subcontractors and com Clete the following information:
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
Owner/Contractor Signature Date