10100188 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10462 MERRIMAN RD CONTRACTOR:ALLIED AIRE SERVICE INC PERMIT NO: 10100188
OWNER'S NAME: PATAKI MARIE A 470 S HILLVIEW DR DATE ISSUED: 10/26/2010
XR'S PHONE: 4089738258 MILPITAS,CA 95035 PHONE NO:(408)934-8844
LICENSED CONTRACTOR'S DECLARATION
��`` �(( BUILDING PERMIT INFO: BLDG ELECT PLUMB
Licen�Class��sO C�'.36 Lic.# �y955i52 cam'
MECH r RESIDENTIAL r— COMMERCIAL
Contractor � � Date � �i /�
I hereby a rrm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:ADD ON A/C
(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. Sq.Ft Floor Area: Valuation:$1850
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. 64d APN Number:34229060.00 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 constriction,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 per the Cupertino Municipal Code,Section Issued by - Date:
9.18.
Signature Date
RE-ROOFS:
LI OWNER-BUILDER DECLARATION 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
I hereby 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
constrict 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
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino 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&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's Owner or authorized agent:
Compensation laws of California. If,after making this certificate of exemption,I Date:
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
upon the above mentioned property for inspection purposes.(We)agree to save
mnify and keep harmless the City of Cupertino against liabilities,judgments,
s,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
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 the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
M.Indoor Air Quality and Fn
1 IAQ/Health pts pyes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts pye 0
3 IAQ/Health pts y=yes p
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 8IAQ/Health pts y=yes 0
6.Use FxteriDr Grade Plywood,for Interior Uses 1 IAQ/Hsab pts y=yes p
7. 41AQ/Health pts yeses 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
N.Flooring
1.Select FSC Certified Wood Flooring _ _ B Resource pts y=yes 0 "
• ° 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 Ayes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
S.Install Recycled Content Carpet with Low VOCs 4 Resource pts y--yes 0
1 1 1
Total Points AvallabTe- 140 . 1-301 57
Total Points Project Received: _ 0
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CITY OF CUPERTINO
FU TACE/AC
CUPEf �TINO PERMIT APP] JICATION FORM
APN# Date:
Building Add re s: Z-16
Owner's Name: Ph a#:
Contractor: Phone#: /67 y-
Fax#:
Contractor License#: Cupertino Business License#:
Contact: Phone#: l{
Fax #: '� �
Building Permit Info:
Elect 5?- Plumb R Mech,g
Residential Eg- Commercial
Job Description:
For Residential Installations:
Attic ❑ I'floor E 2nd floor ❑
Adhere to minimum setback requirement
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction(Usage Class):
Strapped On Platform 0 Bond(d New Locationo Replacement
Project Size: Express �Standard ❑ Large [] Major❑
Valuation:
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, inclu de in plan set & the sheet index.
Revised 01/07/09