09120126 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10660 STOKES AVE CONTRACTOR:SANDIUM PERMIT NO:09120126
OWNER'S NAME: HULTQUIST CHERYL O AND ALLEN W 4223 VERDIGRIS CIR DATE ISSUED: 12/21/2009
VNER'S PHONE: 4082532162 SAN JOSE,CA 95134 PHONE NO:(408)894-9072
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class C20 Lic.# S%k�q REPLACE FURNACE
Contractor Date m121
1 hereby affirm that 1 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:
1 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:$4326
1 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 APN Number:32649008.00 Occupancy Type:
permit is issued.
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
granting of this permit. Additionally,the applicant understands and will comply Issued-by: Date:/
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
-.A 101 RE-ROOFS:
Signat a �...._i� � .. Date All roofs shall be inspected prior to any roofing material being installed. If a roof is
_ installed without first obtaining an inspection,1 agree to remove all new materials for
inspection.
OWNER-BUILDER DECLARATION
Signature of Applicant: Date:_
1 hereby affirm that 1 am exempt from the Contractor's License Law for one o'
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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)
1,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, 1 will
1 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 1
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sens 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 agent: Date:t v
1 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,1 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,1 mus: 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
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
iemnify and keep harmless the City of Cupertino against liabilities,judgments,
(s,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.
Signature Date ______
Community Development
` 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
';UPEkTIN0
Building Department
JOB ADDRESS: PERMIT #
0& 0 0(F1
OWNER'S NAME: PHONE # AOSR ` Z
GENERAL CONTRACTOR: FAX#
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
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
CITY OF CUPERTINO
FURNACEAC
CUPEkTINO PERMIT APPLICATION FORM
12- �0
APN # , Date:
Building Address: o %D
S Aw. ,
Owner's Name: Phone#:
4vS Z53 Zt 6 2
Contractor: Phone#:
Fax#:
Contractor License#: Cupertino Business License#:
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Contact: .SaVALUAl-
Phone#: 4 914
Fax #:
Building Permit Info:
Elect Plumb ['�'' Mech
Residential Commercial ❑
Job Description: ✓%gt� 4xk sa-L* tr LOCI="
For Residential Installations:
Attic ❑ 1" floor �� 2"d 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 ❑ Bonded New Location Replacement
Project Size: Express Eg,--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
CITY OF CUPERTINO
FURNA►CEAC
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description. Fee Permit Type
Group
FURNACE FURN/AC
1 MCRAA Commercial-Rep;tir/Alteration/Add to M
ea heating appliance,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,al)sorption or
evaporative cooli:lg system,incl
installation of controls regulated by this
code.
1MCREPALT Commercial for tie repair of alt/add to M
ea heating appliance,refrigeration
unit,cooling unit;VAV boxes,
absorption unit of ea heathing, cooling
absorption,or eva3orative cooling sys,
incl install of controls regulated by
this code.
1 MCSUSHTR Commercial Instz.11/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted unit heater.
1PGASCOM Commerical for ca gas piping System P
1-4 outlets
1BPGAS For each gas piping system of 5 or P
more per outlet.
1 MCAPPVNT Commercial for tie install/relocate/ or M
replacement of ez. appliance vent
installed ¬ incl in an appliance
permit.
1BCBSC Cal Bldg Standar is Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Commercial Seismic B
1 MRRAA Residential Repa:r/Alteration/Add to M
ea heating appliance,refrigeration unit,
cooling unit,abso.Ttion unit,or ea
heating,cooling,amorption or
evaporative cooling system,incl
installation of controls regulated by
this code.
1 MRSUSHTR Residential InstalI/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted unit heater.
CITY OF CUPERTINO
1P to
FURNACE/AC
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1MRAPPVNT Residential for the install/relocate/ or M
replacement o ea appliance vent
install ¬ incl in an appl permit.
FURNACE FURN/AC
1PGASRES Residential for ea gas piping system of P
1-4 Outlets
1BPGAS For each gas piping system of 5 or P
more per outlet.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Residential Seismic B
1MECPLNCK Mechanical Plan Check M
1 MFR=<100 Furnace Syst =100k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance up to and
include 100,000 Btu/h
1 MFRN>100 Furnace Syst l 00k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance over
100,000 Btu/h
IEPERMITFEE Electric Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit P
1 TRAVDOC Travel Docurr entation B
1 BUSLIC Business Lice lse B
M.indoor Air Quality and Finishes
I-1*ixWlp "P*t 1 IAD/Health pts y=yes p
2.Use Low VOC,Water-Based Wood Finishes 2 IAQMealth pts y=yes 0
S.ij§s L O*bVOGA3 IAQ/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y--yes .0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 6 IAQ/Health'pts y--yes p
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Hean pts y=yes p
�• �� 41AQ/Health pts y=yes p
S.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes p
9.Use Finger-Jointed or Recycled-Content Trim i Resource pts y=yes D
10.Install Whole House Vacuum System 3 IAQ/HeaJth pts y=yes p
' i 1 i
N.Flooring
1.Select FSC Certified Wood Flooring B Resource pts y=yes D
2 Use Rap*Pimewabla FbD!ng Maimials 4 Resource pts y=yes p
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes D
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes p
5.Use Exposed Concrete as Finished Floor 4 Resource pts yeses 0
6,Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes D
Total Points Available: 1401130 57
Total Points Project Received: 0 0 0
G:daW rocs/resnbu➢din uidelines/remo e1C e.1 r
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