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10030048 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21203 OROGRANDE PL CONTRACTOR:BLACK DIAMOND PERMIT NO: 10030048 DESIGNS OWNER'S NAME: MICHAEL ROMELFANGER 3481 DEL NORTE DR DATE ISSUED:03/09/2010 JWNER'S PHONE: 4082535028 SAN JOSE,CA 95132 PHONE NO:(408)272-5959 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL License Class Lic.#� �f (/ SEWER CONNECTION Contractor Date 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. Sq.Ft IIF,6Ak,e f Valuation:$5000 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 Nurl 17018.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the q granting of this permit. Additionally,the applicant understands and will comply Issued by:,�—�7 _ Date: (,t o with all non-point source regulations per the Cupertino Municipal Code,Section ' 9.18. any r ROOFS: Signature s. ate94 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 ❑ OWNER-BUILDER DECLARATION inspection. I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Ch pter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Owner or authorized agen ate: Z(J 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must 1 hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 ,,non the above mentioned property for inspection purposes.(We)agree to save 9emnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION ,;osts,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signat Date %(� CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN 36217018 . 00 DATE ISSUED. . . . . . . : 03/09/2010 RECEIPT #. . . . . . . . . : BS000009898 REFERENCE ID ## . . . : 10030048 SITE ADDRESS . . . . . : 21203 OROGRANDE PL SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA OWNER MICHAEL ROMELFANGER ADDRESS 21203 OROGRANDE PL CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4151 RECEIVED FROM . . . . : MIKE ROMELFANGER CONTRACTOR MUELLER, CRAIG D LIC # 18104 COMPANY BLACK DIAMOND DESIGNS ADDRESS 3481 DEL NORTE DR CITY/STATE/ZIP . . . : SAN JOSE, CA 95132 TELEPHONE (408) 272-5959 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ----- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 5, 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 5, 000 . 00 0.50 0 . 00 0 . 50 0. 00 1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 1PRSEWER UNITS 1 . 00 21. 00 0 . 00 21 . 00 0. 00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 106 . 50 0 . 00 106 . 50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 106 . 50 7522 --------------- TOTAL RECEIPT : 106 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION ------------------------ -------- ---------------------------- 301 ROUGH PLUMBING 507 FINAL PLUMBING CITY OF CUPERTINO REPIPE/SEWER[MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM APN Date: ` Z0/ 6 Building Address: /Z,03 669 0 r 0 Ct ti� O er's Name: Phone#: -2--f- -.570� Contractor: Phone#:a61? i.oar1ye1J1_-) J>ZE-SI6AJ Fax #: Contact: Phone#: f32fF►� i'N�1 t�C_��Z- Fax #: Contractor License#: -7 Cupertino Business License#: !' Job Description: 5t�ZjC�2 G96�t/rUG'�i I a� Residential ,[X Commercial ❑ Valuation: Project Size: Express Standard Large LJ Major 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 1CPSS sewer/sanitary sewer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1PGASCOM Commercial Gas Piping System P 1-4 Outlets 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1 BSEISMICOM Seismic Commercial P Revised 01/07/09 CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE CUPEI,TINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group f 1 BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICR Seismic Residential P 1PRSEWER Residential building P 1RPSS sewer/sanitary sewer 1PRREPIPE Residential re-pipe per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1RPWS 1PPRSEWG Private Sewage Disposal System P 1PCESS Cesspool P 1BPWATER Install/alter Water Pipe P 1 BPFIXTURE Plumbing Fixture P 1PGASRES Residential Gas Piping System P 1-4 Outlets 1BPGAS Gas Piping System 5+ Outlets P 1PPERMITFEE Plumbing Permit Fee Issuance P 1 PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/gas Insp. P 1TRAVDOC Travel & Documentation Fee B 1BUSLIC Business License B 1 1612211 M.Indoor Air Qua rty an Finishes 1.Use LowMo-VOC Paint 1 IAQ/Health pts y=yes 6 2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 3.Use Low No VOC Adhesives 3 IAQ/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 Formaldehyde 61AQ/Health pts y--yes 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0 7.Seal al EVOsed Partioleboard or MDF 41AQ/Health, pts y=yes 6 S.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes0 9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes D 10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 1 1 N.Flooring 1.Select FSC Certified Wood Flooring B Resource pts y=yes 0 2.Use Rapidly Renewable.Flooring Materials 4 Resource pts y=yes � 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=yes 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 01 1 1 1 1 Total Points Available: 140 130f 57 Total Points Project Received: 0 0 0 3 ��D G:datalprogslgreenbuildingguidelineslremodelerslgreenpointsfina1212 Mproteoted.zls Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 CITY OF 'UPEkTINO Buil din De artme nt JOB ADDRESS: PERMIT # J PHONE #40j9 -n21� OWNER'S NAME• ,i �- r FAX # GENERAL CONTRACTOR: / .0 I am not using any subcontractors: Date Signature Please check a licable subcontractors and complete the folloEinBUSINESS LICENSE # SUBCONTRACTOR BUSINESS NAM 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