10080133 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 855 BETTE AVE CONTRACTOR:JAMES DENOYER PERMIT NO: 10080133
OWNER'S NAME: JAMES DENOYER 855 B ETTE AVE DATE ISSUED:08/19/2010
SER'S PHONE: 4087170827 CUPS RTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATIONr— r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH r RESIDENTIAL r COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALL A/C UNIT
(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.D Floor Area: Valuation:$1300
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. APN Slumber:36927043.00 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 per the Cupertino Municipal Code,Section Issued Date: " —,/JC_le
9.18.
Signature Date
RE-ROOFS:
OWNER-BUILDER DECLARATION All ro ifs 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:
I,as owner of the property,or my employees with wages as their sole compensation, Signa ure of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
1,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 hav,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 Califs rrnia Health&Safety Code,Sections 25505,25533,and 25534. I 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. Safet,i Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Addii ionally,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. main ain 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 Own4!r or autho ager : n
Compensation laws of California. If,after making this certificate of exemption,I 'goDate: O —
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
�{{J I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for w rich 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
i^' --mify and keep harmless the City of Cupertino against liabilities,judgments,
and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
guu...mg of this permit.Additionally,the applicant understands and will comply I and:rstand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licer sed Professional
Signature Date "-w/
CITY OF CUPERTINO
4 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36927043 . 00
DATE ISSUED. . . . . . . : 08/19/2010
RECEIPT #. . . . . . . . . : BS000011223
REFERENCE ID # . . . : 10080133
SITE ADDRESS . . . . . : 855 BETTE AVE
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : JAMES DENOYER
ADDRESS . . . . . . . . . . : 855 BETTE AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : JIIM J DENOYER
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : JAMES DENOYER
ADDRESS . . . . . . . . . . : 855 BETTE AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 1, 300 . 00 1. 00 0.00 1. 00 0 .00
1BREMAIRHA NO.UNITS 1. 00 63 . 00 0 .00 63 . 00 0 .00
1MPERMITFE FLAT RATE 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 148 . 00 0 .00 148 . 00 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY
502 FINAL PLUMBING ENERGY 503 FINAL MECHANICAL ENERGY
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
CITY OF CUPERTINO
FEE ESTIMATOR- BL ILDING DIVISION
ADDRESS: I DATE: REVIEWED BY:
APN: BP#: *VALUATION: 1$1,300
FPERMIT TYPE: Mechanical Permit PLAN CH ECK TYPE: Alteration/Addition/ Repair
PRIMARY 107 ,1 L PENTAMATION 1 RMAP2
USE: SFD or Duplex II_C)C)tZ.tlti1;1. PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY BP FEES
A/C Units (<=10K cfm) 1BREMAIR 1 $63
TOTALS: $63.00
Mech.Plan Check0.0 hrs $0.00
Mech.Permit Fee: IMPERMIT /,riu r t'�°r r<<r F", ii.'�r Per tr rr V-12"
Other Mech.Insp. 0.0 hrs
/n p /'c''-
NOTE: Theseees are based on the preliminaryinformation available and are onl an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 09-05I Eff. 7%UlDj FEE QTY/FEE MISC ITEMS
Poll Check Fec
drip[ PC 1 cue,
PME Plan Check: $0.00
Permit /`e c:
Supp/, 111y Fee F71
PME Unit Fee: $63.00
PME Permit Fee: $42.00
COIIStr ICIiO7 i',Lt
tr:r�ttslir:c,1 16,vic , 1,cc.
Work Without Permit? 0 Yes 0 No $0.00
Travel Documentation Fee: ITRAVDOC $42.00
.SIn'.ltr oli'm Fcc- Select an Administrative Item
BIdyStds Commission Fee: IBCBSC $1.00
SUBTOTALS: r $148.00 $0.00 TOTAL FEE: $148.00
Revised: 8/17/2010
J CITY OF C UPERTINO
FUNA��E%AC
CUPEkTR
iNO PERMIT APPLICATION FORM
APN # � � _ Date:
Building Address:
Owner's Name: Phone#:
�l /c IV c/,2 Y� � �r ��
Contractor: Phone#: � $' Tff 7 �y
a("-? 4(k T �,C' y Fax#:
Contractor License#: Cupertino Business License#:
Contact: Phone#:
j l k,17 Fax#:
Building Permit Info:
Elect E;"` Plumb Mech
Residential ID Commercial
Job Description:
For Residential Installations:
Attic ❑ 1" floor � 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 roject: Type of Constrµmotion(Usage Class):
l3 �
Strapped On Platform Bonded7 r New Location " 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, include in plan set & the sheet index.
Revised 01/07/09
M.lndDDr Air-Quality and Finishes
1.use ilowftio-yoC Faint 1 U DMealth ptr. y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 I/,Q/Hsab pts y=yes 0
3.;Use Loulip VOC Adlisiues 3 I/DBealth pts y-yes 0
4.Use Salvaged Materials for Interior Finishes 3 F esource pts yeses D
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 5 VD/Health pts y=yes 0
6.Use Exterior Grade Plywood for Inferior Uses 1 I{D/Health pts y=yes D
7-Sed-4_ el gr.MI)FF - _ 4l/D/Health is - es
B.Use FSC Certified Materials for Interior Finish 4 F eswme pts y--yes D
9.Use Finger-Jointed or Recycled-Content Trim 1 F esource pts y=yes 0
10.Install Whole House Vacuum System 31 NQ/Health pts y=yes p
1 1 D
N.Flooring
1.Select FSC Certified Wood Flooring B RE source pts y=yes 0
2.19se lf3ap l fi ble F7ooripg Matanats4 Resource pts y-yes D
3.Use Recycled Content Ceramic Tiles- 4 RE source pts y=yes D
4.Install Natural Linoleum in Place of Vinyl 5 IA:)/HeaJth pts y=yes p
5.Use Exposed Concrete as Finished Floor 4 Resource pts yryes D
S.Install Recycled Content Carpet with Low VOCs 4 RE source pts y--yes 0
Total Points Available: 1401 1301 57
Total Points Project Received: 01 01 0
G:daWprog91jreenbufir ingguidelineshemodelerslgreenp6intsfina1212Mp laDisdAs
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMEN r• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 9 5014-3255
(408)777-3228• FAX(408)777-3333- buildinQQCUDerbno.org
CUPERTINO
Dear Property Owner(s):
An application for a building permit has been submitted in your r ame listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS / APN`�G D BP#
OWNER NAME OWNER ADDRESSy���l4`e�/ Z/�,�I p�
DESCRIPTION OF WORK: 7
001
We are providing you with an Owner-Builder Acknowledgment end Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having t-iis permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read, initialecl your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you,the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF IN=ORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
1. 1 understand a frequent practice of unlicensed persc ns is to have the property owner obtain an "Owner-
Builder" building permit that erroneously implies that the prc perty owner is providing his or her own labor and.material
personally. I, as an Owner-Builder, may be held liable and ,,ubject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as e n Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
Z 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
_7V 3. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred doilars ($500), including labor and materials, I may be
considered an"employer" under state and federal law.
6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and
federal government,withhold payroll taxes, provide worker:'compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
-0 7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intE nt to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general buildin 3 Contractor.
IV 8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsegUent owner(s)that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04/14110