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10100165CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 20150 APPLE TREE LN CONTRACTOR:' ' PERMIT NO: 10100165 OWNER'S NAME: KURTZ FRED N AND DONNA L i K� K-4 L �—k o DATE ISSUED: 10/22/2010 NER'S PHONE: 4084465554 ❑ LICENSED CONTRACTOR'S DECLLARATION License Class -4-;- Lic. # Contractor sy C- 1 h e, 14 Date ZZ 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. 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 Section 3700 of the Labor Code, for the performance of the work forw ich 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 � � \� a -Q" Date © l v OWNER -BUILDER DECLARATION I 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 ^aemnify and keep harmless the City of Cupertino against liabilities, judgments, , and expenses which may accrue against said City in consequence of the b....Aing 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 Date —1 C, A2— I PHONE NO: IWILDING PERMIT INFO: BLDG f— ELECT r— PLUMB I— MECH r— RESIDENTIAL r- COMMERCIAL f— (OB DESCRIPTION: REMODEL BATHROOM(56SQ) NEW TILE SHOWER -LOOR,VANITY SINK,FAUCET,LIGHTS FOR HEAT LAMP;NO tE-ROOF & NO STRUCTURAL Sq. Ft Floor Area: APN Number: 31633078.00 Valuation: $12500 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by Date: 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. Owner or aut r' ed Dater 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. Licensed Professional CITY OF =ERTINO 3 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN ......... 31633078.00 DATE ISSUED.......: 10/22/2010 RECEIPT #......... BS000011817 REFERENCE ID # ...: 10100165 SITE ADDRESS .....: 20150 APPLE TREE LN SUBDIVISION ...... CITY CUFERTINO IMPACT AREA ...... OWNER ............: KUFTZ FRED N AND DONNA L ADDRESS 20150 APPLE TREE LN CITY/STATE/ZIP ...: CUFERTINO, CA 95014-2002 RECEIVED FROM ERIC KALLIO CONTRACTOR TBI, - TO BE DETERMINED LIC # 00096 COMPANY TBIi - TO BE DETERMINED ADDRESS .......... CITY/STATE/ZIP ...: TELEPHONE ........ FEE ID UNIT QUANTITY IiMOUNT PD -TO -DT THIS REC ------ NEW BAL ----------------------- 1BCBSC VALUATION ---------- 12,500.00 ----------- 1.00 ---------- 0.00 1.00 0.00 1BSEISMICR VALUATION 12,500.00 1.30 0.00 1.30 0.00 1REMRESBAT SQ FEET 56.00 570.00 0.00 ---------- 570.00 ---------- 0.00 ---------- TOTAL PERMIT ---------- 572.30 0.00 572.30 0.00 -sa - 1 IAQ/Health pts y=yes 2. Use Low VOC, Water -Based Wood Finishes 2 IAQ/Health pts y=yes, S. Use tDolkVOGJ4 3IAQ/Health pts y=yes 4. Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 5. Use Engineered Sheet Goods with no added Urea 5 IAQ/Health pts y=yes Formaldehyde 6IAQlHealth pts y=yes 5. Use Exterior Grade Plywood.for Interior Uses 1 IAQ/Health pts y=yes ��11l 41AW 41AQ/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 3 Resource pts y=yes Use fialudly Renewable 9oafinq MaWWs 1 Resource pts y=yes 3. Use Recycled Content Ceramic Tiles 1 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 1 Resource pts y=yes 6. Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes Total Points Avails le: 1 1401 1301 57 Total Points Project Received: 01 01 0 Matalprogslgre tnbuildingguiderines/remodelerslgreenp6intsfinal21204proteoted.xls CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: ' o PERMIT # OWNER'S NAME: PHONE # GENERAL CONTRACTOR: t_C_L(; BUSINESS LICENSE # ADDRESS: -20 C) CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino busigess license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONT ZACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: l b S ignature Date Please check applicable subcontractors and complete the following information: Owner / Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature Date �X) www, zf m I Al m ,tJ- - w 7D, (TI 77 ,tJ- - w 7D, (TI b5 CITY OF ACU ?ERTINO ADDITION/REMODEL FEE M --MEDDLE -, .3l (� 33 X078 Is a 2n unit being added? Yes L No B jdin ddress• Mailing Address (i different from buildir O 's Cru��" ontractor: ;E—� 124 C_ V_44,q 6 ino Business License: &L-4 If address': Landscape Ordinance Compliance: Landscape area in sq. ft. (includes all irrigated a reas): If 2,500 sq. ft. or less, compliance with the Landscape Water -Efficiency Checklist is required. If more than 2,500 sq. ft., a complete Landscape Project Submittal is required. Compliance Method• ❑Plant Type Building P t Info: [� Elect. Plumb. Job Description: Addition -What is being added?(Be Specific): What is being remodeled (not including addition)? es list number of squares Remodel Includes Re- no Yes No f Y q Remodel Includes Structural: Yes ❑ No 3 Do you have the pre -application planning approval. If _yes, please provide a copy of your planning appro, Square Footage: Addition: Porch: Deck: _ I� Remodel: Kitchen Bath _ Type of Construction (Usage Class): 1-A, 1-B ❑ H/IIIN-A ❑ IUIII B Other IV -HT, V -B Garage: Detached Attached 'roject Size• Express Standard ❑ Large [] Major L Please complete relevant portion of the Green Building Checklist &attach it to the application or if applicable, include in plan set & the sheet indez. Revi ,,ed 05/18/10