10020007CITY OF CUPERT0 O BUILDING PERMIT
BUILDING ADDRESS: 1129 YORKSHIRE DR
r`•"NER'S NAME: DELOOF ERNA L AND RICHARD E
t,,, NER'S PHONE: 4082524206
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
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.
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.
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.
q; -nature Date.
411 OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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,
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
�n the above mentioned property for inspection purposes. (We) agree to save
.mnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may acc against said City in consequence of the
granting of this pe Ad 1 the app icant understands and will comply
with all non-pou so ce regul i si per tCupertino Municipal Code, Section
9.18. 111 1'J0
Signature � Dat
CONTRACTOR: DELOOF ERNA L AND PERMIT NO: 10020007
RICHARD E
1129 YORKSHIRE DR DATE ISSUED: 02/01/2010
CUPERTINO CA, CA 950144916 PHONE NO:
BUILDING PERMIT INFO: BLDG r— ELECT r PLUMB r
MECH r RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: REPLACE 1 I OA POWER PANEL WITH 2O0A PANEL
Sq. Ft Floor Area: Valuation: $1000
APN Number: 36207017.00 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by_*�
J�---,.-_— z_---- Date:,_/ -14
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 . h tie Cu rtino Municipal Code, Chapter 9.12 and the
Healt//h &4S ety Code S coons 05, 25533, and 25534.
Date • l✓
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
5 ITEMS OF 5
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blc: Lot:
APN ........: 36207017.00
DATE ISSUED.......: 02/01/2010
RECEIPT #......... BSDO0009659
REFERENCE ID # ...: 10]20007
SITE ADDRESS 1129 YORKSHIRE DR
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......
OPERATOR: patg
COPY # : 1
OWNER DELOOF ERNA L AND RICHARD E
ADDRESS 1129 YORKSHIRE DR
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4916
RECEIVED FROM ....: DICK DE LOOF
CONTRACTOR LIC # *OWNER*
COMPANY DELOOF ERNA L AND RICHARD E
ADDRESS 1129 YORKSHIRE DR
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4916
TELEPHONE ........
FEE ID UNIT
QUANTITY
AMOUNT PD -TO -DT
THIS REC
----------
NEW BAL
-----
-----------------------
1BCBSC VALUATION
----------
1,000.00
--------------------
1.00
0.00
1.00
0.00
1BSEISMICR VALUATION
1,000.00
0.50
0.00
0.50
0.00
1EPERMITFE FLAT RATE
1.00
42.00
0.00
42.00
0.00
1ERT<200 UNITS
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
---------- ----------
127.50
0.00
127.50
0.00
METHOD OF PAYMENT
AMOUNT
REFERENCE
--------------------
NUMBER
----------------- ---------------
CHECK
127.50
#1285
---------------
TOTAL RECEIPT
127.50
OWNER -BUILDER. VERIFICATION
1. (Check one) I or my immediate family (parent, spouse or child) will perform:
A. All the work authoriz :!d by this permit
B. _ A portion of the work
C. _ None of the work
If B or C is checked, complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. All of the work
B. _ A portion of the wort (complete section below)
Phone # State License # Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' comp ?nation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
performed
.................................................................................,..........i.........4 ........................
I declare under penalty of perjury t e abo•i is true a correct: I have read_ and understand the
Owner -Builder Information (rev .se si a .�
Property Owner's Signature: Date:
Job Address:
1 / J r� r' Permit # lJyy� t I
Ani changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
a_-tV-10
CITY OF CUPERTINO
CUPEfZTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN #
Date:
Building Address//)I-)
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes ❑ No FW
i
HOA: Exterior work only) Yes ❑ No F71 --Irf yes, provide letter from HOA
Owner's Name: `
Phone #
Contractor:
Phone:
Fax:
Contractor License #:
Cupertino Business License #:
Contact:
Phone:
Fax:
Residential Commercial ❑
Job Description:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Type of Construction (Usage Class):
Occupancy Type:
1-A 1-B II/IIIN-A ❑ II/III B, IV -HT, V •B
[12 - . -
Valuation: ! Square Footage:
Project Size: Express n and ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicab le, include in plan set & the sheet index.
Points Achieved:
I For help, contact Build it Green at www.builditg-een.or
Revised 07/14/09
-911 SNI -1
CITY OF
CUPEI�TINO
CITY OF CUPERTINO
GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf
Fee ID
Fee Description
Fee
Group
Permit Type
1GENRES or
1GENCOM
1STUCOAP
Stucco Applications (up to 400 sf)
additional stucco application
B
1 WINREP
Replaceir ent windows/sliding glass
door (ea 3 windows)
B
1 WINMEWSTR
New Window -structural shear
wall/masonry (includes plan ck fee)
B
I EPERMITFEE
Electrical Permit Fee
E
IMPERMITFEE
Mechanical Permit Fee
M
IPPERMITFEE
Plumbin€, Permit Fee
P
1 ELCPLNCK
Stand Alone Electric Pln Ck (hourly)
E
1 MECPLNCK
Stand Alone Mechanical Pln Ck (hrly)
M
IPLMBLNCK
Stand Alone Plumbing Pln Ck (hrly)
P
1 STPLNCK-(3 Hr Min
when not over counter)
Standard Plan Check (when no E/M/P)
hourly -stand alone
B
/
1BCBSC
Cal Bldg Standards Commission Fee
B
ALL PERMIT
TYPES
IBSEISMICR
Seismic lesidential
B
IBSEISMICO
Seismic 2ommercial
B
1 TRAVDOC
Travel &: Documentation
B
IBUSLIC
Business License
B
5 of 5
N. Flooring
1. Select FSC Certified Wood Flooring
IAQ/Health pts
y=yes!
2. Use Low VOC, Water -Based Wood Finishes
? IAQ/Health pts
y=yes.
3. Use LD*ft i=AdM,6M
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
Resource pts
y=yes
Formaldehyde
31AQ/Health pts
y=yes
6. Use Exterior Grade Plywood for Interior Uses
1 IAQ/Health pts
y=yes
7. $W ' ` iF
4 IAQ/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
E Resource pts
y=yes
2. Use Rap* Renewable Flooring Materials
z Resource pts
y=yes
3. Use Recycled Content Ceramic Tiles
1 Resource pts
y=yes
4. Install Natural Linoleum in Place of Vinyl
i IAQ/Health pts
y=yes
5. Use Exposed Concrete as Finished Floor
Resource pts
y=yes
6. Install Recycled Content Carpet with Low VOCs
Resource pts
y=yes
Total Points Available:I 140t_130 57
Total Points Project Received: 01 01 0
2,-1,10
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