10010076 • CUPERTINO BUILDING PERMIT
CITY OF
CONTRACTOR-.TBD-TO BE DETERMINED PERMIT NO:10010076
BUILDING ADDRESS: 10310 STONYDAL9 DR
DATE ISSUED:01/19/2010
OWNER'S NAME: HENDRICKSON MARY E TRUSTEE PHONE NO:
NER'S PHONE: 4087320906 FELECT PLUMB
BUILDING PERMIT INFO: BLDG
� LICENSED CONTRACTOR'S DECLARATION COMMERCIAL
,., e MECH RESIDENTIAL
G 2 Lic.#
License Class /� 20,11
NICAL INC P
Date DESCRIPTION:REPLACE EXISTING FURNACE;R.C.MECHA
Contractor � �� �C fir ,�� JOB
I hereby affirm that I am licensed under the pvisions of Chapter 9 FOR
BUS LIC
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
b affirm under penalty of perjury one of the following two declarations:
I here y
I have and will maintain a certificate of consent to self-in
ure 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. provided for by Valuation:$2556
I have and will maintain Worker's Compensation Insurance,as Ft Floor Area:
700 of the Labor Code,for the performance of the work for which this Sq. e•
Section 3 Occupancy Type:
permit is issued. APN Number:32637030.00
APPLICANT CERTIFICATION
i that I have read this application and state that the ao and state laws relating
ation is
I certify 1 with all city and county ordinances
correct.I agree to comply authorize representatives of this city to enter PIKES IF WORK IS NOT STARTS
to building construction,and hereby inspection purposes. (We)agree to save PERMIT EX IT ISSUANCE OR
upon the above mentioned prop fO of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERM INSPECTION.
indemnify and keep harmless theCity in consequence of the
s which may accrue against said City gill comply p DAYS FROM LAST CALLED INS
costs,and expense applicant understands and p ig �
granting of this permit. Additionally,the app
all non-point source regulations per the Cupertino Municipal Code,Section Date: /
with
9.18. Issued by:
Date 2
Signature
RE-ROOFS:
OWNER-BUILDER DECLARATION prior to any roofing material being installed.If a roof is
U hob first obtaining an inspection,I agree to remove all new materials for
t from the Contractor's License Law for one of All roofs 11 d w shall be inspected p
I hereby affirm that I am exempt installed
the following two reasons:or my employees with wages as their sole compensation, inspection. Date:
1,as owner of the property, Applicant:will
do the work,and the structure is not intended or offered for sale(Sec.704 , Signature of App
Business&Professions Code) with licensed contractors to
caner of the property,am exclusively contracting
I,as
u ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code
hereby affirm under penalty of perjury one of the following three
e HAZARDOUS MATERIALS DISCLOSUREChapter 6.95 of the
Ih ynder
declarations:
'n a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements s 2550525533,and 25534. I will maintain
I have and will maintai Code,Sect
as provided for by Section 3700 of the Labor Code,for the California Health&Safety Chapter 9.12 and the Health&
Compensation, compliance with the Cupertino Municipal Code, ous hazard
provided for by Code,Section 25532(a)should I store or handle emit hazardous air
performance of the work for which this permit
Insurance,as p Safety equipment or devices which I have and will maintain Worker's Comp Additionally,should I use eghe Bay Area Air Quality Management District I will
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by Municipal Code,Chapter 9.12 and the
permit is issued. work for which this permit is issued,I shall maintain compliance with the Cupertino
the performance of the wo Worker's Health&Safety Code,Sections 25505,25533,and 25534.
I certify that in p
not employ any person in any manner so as to become subject to the o - 149 2v/�
of Owner or uth agen • -4
Compensation laws of California. If,after making this certificat Labor Codeol must Date:
provisions of the
become subject to the Worker's Compensation p
with comply with such provisions or this permit shall be deemed revoked.
forth CON STRUCTION LENDING AGENCY
N that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION I hereby affirm
read this application and state that the above information
relating for which this permit is issued(Sec.3097,Civ C.)
I certify that I have ordinances and stateLender's Name
correct.I agree to comply with all city and county
building construction,and hereby authorize representatives ntoas Ses of t is cit to saveent ddress
er
to g for inspection purposes. Lenders A
upon the above mentioned property of Cupertino against liabilities,judgments,
lnify and keep harmless the City p in consequence of the
and expenses which may accrue against said City ARCHITECT'S DECLARATION
applicant understands and will comply
granting of this permit.Additionally,the app I understand my plans shall be used as public records.
11 non-point source regulations per the Cupertino Municipal Code,Section
with a p
9.18. E
Date � 201Z? Licensed Professional
Signature
a
CITY OF CUPERTINO
RECEIPT OPERATOR: patg
PERMIT Copy # 1
8 ITEMS OF 8
Sec: Twp: Rng: Sub: Blk: Lot:
APN 32637030 . 00
DATE ISSUED: : : ; : : : 01/19/2010
; BS000009583
RECEIPT # 10010076
REFERENCE ID #
STONYDALE DR
SITE
ADDRESS . . . . . : 10310
SUBDIVISION : : : : : : : CUpERTINO
CITY - • •
IMPACT AREA • • • • •
• „ • , : HENDRICKSON MARY E TRUSTEE
OWNER 10310 STONYDALE DR
ADDRESS CUPERTINO CA, CA 95014-1030
CI'T'Y/STATE/ZIP
RECEIVED FROM
SAL CONTRERAS LIC # 00096
- • • TBD - TO BE DETERMINED
CONTRACTOR. : : ; : : : : • TBD - TO BE DETERMINED
COMPANY
ADDRESS - • • " '
CITY/STATE/ZIP
TELEPHONE . . . . . . . .
PD-TO-DT
THIS REC NEW BAL
SIT QUANTITY _AMOUNT--- ---------- ---------- ------- .00
FEE ID -_-------- 1 . 00 0
_----------- 1 . 00 0 .00 0 . 00
---------- 2, 556 .00 0 .00 0 .50
1BCBSC VALUATION 21556 .00 0 . 50 .00 114 . 00 0 .00
114 .00 0 0 . 00
1BSEISMICR VALUATIONTE 1 .00 0 ,00 42 . 00
1BUSLIC FLA 1 .00 42 .00 42 .00 0 . 00
42 . 00 0 .00 0 . 00
1EPERMITFE FLAT RATE 1 .00 0 .00 63 .00
1MPERMITFE FLA 1 . 00 63 . 00 42 . 00 0 .00
UNITS 42 . 00 0 .00 0 .00
1MRRAA 1 . 00 0 . 00 42 . 00 ___
1PPERMITFE FLAT RATE 1 .00 42 . 00 -------
1TRAVDOC FLAT RATE ___--- --------- 346 . 50 0 . 00
346 .50 0 .00
TOTAL PERMIT :
�o.�,r REFERENCE_NUMBER
METHOD OF PAYMENT -_________
----------------- 346 .50 VISA
CREDIT CARD _______________
346 . 50
TOTAL RECEIPT : VOICE ID _DESCRIPTION
____-_-__
VOICE ID DESCRIPTION_-_---___ -------
--------------- 507 FINAL PLUMBING
505 FINAL ELECTRICAL
508 FINAL MECHANICAL
7
c A
CITY
OF CUPERTINO
FURNACE/AC
"n. .;Of
APERMIT
CUPE TINO
C �..
Date: � l�
APN
�7
Building Address:..
03 / Phone#:
Owner's Name:
Phone#: S�._ r -- ��✓1
Contractor:
Fax#:
Cupertino Business License#:
Contractor License#:
Phone#:6 5-0_ S-?5--' 3�/ 5—
Contact:
Fax#:
15 4
Building Permit Info:
Elect Plumb
Mech
Commercial ❑
Residential
Job Description:
Residen al Installations. A 2nd floor ❑
For 1 floor
Attic ❑
Adhere to minimum setback requirement ❑
For
Commercial Installations: Additional weight(structural calcs) ❑
same Replacement me weight ❑
p e uire
Structural Calculations rd for new installation D
q royal Required ❑
T
New installation Planning App e Class
Cost of Project:
Type of Construction (Usag ):
N
ew Location❑ Replacement
Strapp
ed On
...... Platform ' Bon ded❑
Lar e[I Major❑
Project Size: Express ❑ Standard❑
Valuation:
• Green Building Checklist & attach it to the
• : Please complete relevant porton of the & the sheet index.
Green Building applicable, include in plan set
application or if
Revised 01/07/09
CITY OF
CUPERTINO
FURNACEAC
CITY of FEE
SCHEDULE
CUPEkTINO
Fee Permit Type
Fee ID Fee Description Grou ,
Quantity
Residential for the install/relocate/ or
M
1MRAPPVNT
replacement of ea appliance vent
install ¬ incl in an appl permit.
FURN/AC
FURNACE
i in s stem of P
GASRES
1P
Residential for ea gas p p g y
1-4 Outlets P
1BPGAS
For each gas piping system of 5 or
more per outlet. • B ALL PERMIT
IBC
BSC Cal Bldg Standards Commission Fee TYPES ----------
SEISMICR Residential Seismic
B
1B
PLNCK Mechanical Plan Check
M
1 MEC
Furnace Syst<=100k BTU install or
M
1 MFR=<100
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance up to and
include 100,000 Bt install or M
1 MFRN
>100 Furnace Syst> I 00k BTU
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance over
100,000 Btu/h E
1
EPERMITFEE Electric Permit Fee
pERMITFEE Mechanical Permit Fee
M
1M
PERMITFEE Plumbing Permit
P
1P
VDOC Travel Documentation
B
1 TRA
B
1BUSLIC Business License
E
CITY OF
CUPERTINO
E/AC
FURNAC ,,,.
cln of EE SCHEDULE
CUPEf�TINO
F
Fee Permit Type
, Fee ID Fee Description Grou
Quantity FURN/AC
A_
CONDITIONING <= 10k CFM B
IRHAN Commercial A/C Units
1 BCA
1 MC
RAA Commercial Mech Rep
air/alt/add M
ALL PERMIT
Cal Bldg Standards Commission Fee B APES
1BCBSC TY
ISMICO Seismic Commercial
B
1BSE
i
1 PGAS
COM Commerical for ea gas piping in g System P
1-4 outlets P
1PGASRES
Residential for ea gas piping system
of 1-4 Outlets of 5 or P
1BPGAS For each gas piping system
more er outlet. Comm/Resid B
1 BREMAIRHAN
Residential A/C units<= lOk CFM
Residential Mech Repair/alt/add
M
1 MRRAA
ssion Fee B ALL PERMIT
1 BCB
SC Cal Bldg Standards Comm' TYPES
SMICR Seismic Residential
B
1BSEI
E
1 EPERMITFEE Electric Permit
ERMITFEE Mechanical Permit
M
IMP
pERMITFEE Plumbing Permit
P
1P
B
VDOC Travel Documentation
1 TRA B
1 BUSLIC Business License
P.In or Air Quality and rinishes 0
1 IAQ/Health pts y=yes 0
1'UsetNC' -Voc P 2 IAQ/Health pts y=yes.
2.Use Low VOC,Water-Based Wood Finishes 0
31AQ/Health pts y=yes
3'Use Lo (C Adllss 0
3 Resource pts y=yes
4.Use Salvaged Materials for Interior Finishes
5.Use Engineered Sheet Goods with no added Urea 0
Formaldehyde 6IAQ/Health pts y=yeS 0
1 IAQ/Health pts y=yeS 0
6.Use Exterior Grade Plywood for Interior Uses 4 IAQ/Health pts y—yes
' . _,axe p
7. 4 Resource pts y=yes
8.Use FSC Certified Materials for Interior Finish 1 Resource pts y=yeS 0
9.Use Finger-Jointed or Recycled-Content Trim 3 IA0
IAQ/Health pts y=yes
10.Install Whole House Vacuum System i
N.Flooring 0
8 Resource pts y=yes
1.Select FSC Certified Wood Flooring 4 Resource pts y—yes 0
2.Use Rapdy Renewable Flooring Materials Y=Yes
3.Use Rmycl9d Conte
nt Ceramic Tiles 4 Resource pts y=yeS p
5 IAQ/Health pts y=yes
4.Install Natural Linoleum in Place of Vinyl 0
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
MENOMONEE
Total Points Available: 1401 1301 57
c
MINE01 01 L0
Total Points Project Received:
00
r
G:datalprogs/greenbuildingguidelines/remodelers/greenpointsfinal2.12.44protected.xis ''
Community Development
10300 Torre Avenue
;.
Cupertino CA 95014
Telephone 408 777-3228
„*may Fax(408)777-3333
CtT1f Of
..UPE TIT
artment
Buildion De
PERMIT #
VOWNEXSNMME--
ADDRESS: ,�
V4
L PHONE # -e Ole-
4RR 5 0 # - 3 5707
ONTRACTOR: FAX
GENERAL C W
q �lQ
I am not using any subcontractors: at
Signature
subcontractors and complete lete the f ollowi.n information:
Please check applicable s ICENSE #
SUBCONTRACTOR ONTIZACTOR BUSINESS NAME BUSINESS L
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
1
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Date
Owner/Contractor Signature