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09110070 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10150 MELLO PL CONTRACTOR:SUSTAINABLE SPACES PERMIT NO:09110070 INC O"'MFR'S NAME: TIM WIDMAN 1167 MISSION ST DATE ISSUED: 11/12/2009 Off. rER'S PHONE: 4153945380 SAN FRANCISCO,CA 94103 PHONE NO:(415)294-5380 LICENSED CONTRACTOR'S DECLARATIONf— License Class Lic.# 2 I* ' BUILDING PERMIT INFO: BLDG ELECT PLUMB fit' MECH F_ RESIDENTIAL f— COMMERCIAL Contractor 5kff .11""� Date t 1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:ICYNENE INSULATION(FLOOR),HRV INSTALL, (commencing with Section 7000)of Division 3 of the Business&Professions DUCT Code and that my license is in full force and effect. REPLACEMENT,FURNACE INSTALL,WHOLE HOUSE FAN(WITH ELECTRICAL)(ICYNENE IN CRAWL WILL NOT BLOCK ANY 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 Sq.Ft Floor Area: Valuation:$20000 permit is issued. APPLICANT CERTIFICATION APN Number:36905026.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non- t source regu tions per the Cupertino Municipal Code,Section 9.18. Si +ure Date_(( (� Q Issued by: l ❑ OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the stricture is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should 1 store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's HealthA Safety Code,Sec ons 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,1 become subject to the Worker's Compensation provisions of the Labor Code,I must OWa oC forthwith comply with such provisions or this permit shall be deemed revoked. 14Date: (t l APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name I he above mentioned property for inspection purposes.(We)agree to save i, nify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address 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 ARCHITECT'S DECLARATION 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 36905026 .00 DATE ISSUED. . . . . . . : 11/12/2009 RECEIPT #. . . . . . . . . BS000009180 REFERENCE ID # . . . : 09110070 SITE ADDRESS . . . . . : 10150 MELLO PL SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER TIM WIDMAN ADDRESS 10150 MELLO PL CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-3336 RECEIVED FROM . . . . : RYAN BOOTH CONTRACTOR PRATAP MUKHERJEE LIC # 27861 COMPANY SUSTAINABLE SPACES INC ADDRESS 1167 MISSION ST CITY/STATE/ZIP . . . : SAN FRANCISCO, CA 94103 TELEPHONE (415) 294-5380 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BAPPLOTHE NO OF APPLIAN 1 . 00 63 . 00 0 . 00 63 . 00 0 . 00 1BCBSC VALUATION 20, 000 . 00 1 .00 0 . 00 1. 00 0 .00 1BREMVENFA NO UNITS 1. 00 0 . 00 0 .00 0 . 00 0 . 00 1BSEISMICR VALUATION 20, 000 . 00 2 . 00 0. 00 2 . 00 0 . 00 1EPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 .00 1MPERMITFE FLAT RATE 1. 00 42 .00 0 . 00 42 . 00 0 .00 1MRRAA UNITS 1. 00 63 . 00 0 .00 63 . 00 0 . 00 1PPERMITFE 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 297 . 00 0 .00 297 . 00 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 297 .00 VISA --------------- TOTAL RECEIPT 297 . 00 c-7 � CITY OF CITY OF CUPERTINO GENERAL BUILDING CUPERTINO PERMIT APPLICATION FORM APN# Date: � 0 -)— In • -0 `_� It Building Address: Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes ❑ No [� HOA: Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA Owner's Name: Phone#: Contractor: Phone: -Z 14 5 1�0 Fax: Contractor License#: �'7� Cupertino Business License #: Contact: v Phone: � j • '71) 5 23—7 Fax: Residential Commercial ❑ Job Description: I& n� l n' c-hak M'Our), �" l n6Fv�u 6L v^4 - kk r Vk att, LU k 11 Lk, (TNvve pie i vi L v-Awl l +� v+� l �a l a�,�' 6�-►.''..� :v e,v� K 1C = 1 Vw I 1't e q�" .S Value z 3 �I Nl t ,79� Building Permit Info: Bldg V Elect [ Plumb ❑ Mech Type of Construction(Usage Class): Occupancy Tlype: 1-A, 1-B ElII/III/V-A ElII/VI B, IV-HT,V-B E] , " T Valuation:� �0 1 6,cz Square Footage: Project Size: Express M, Standard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it to the application or if applicable, include in plan set& the sheet index. Points Achieved: For help,contact Build it Green at www.builditgreen.org Revised 07/14/09 CITY OF CITY OF CUPERTINO GENERAL BUILDING APPLICATION CUPERTINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door ea 8 windows 1 WINMEWSTR New Window-structural shear B wall/mason includes plan ck fee IEPERMITFEE Electrical Permit Fee E 1MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck(hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck(hrly) M 1 PLMBLNCK Stand Alone Plumbing Pln Ck(hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check(when no EA /P) B when not over counter) hourly-stand alone r 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT I TYPES 1BSEISMICR Seismic Residential B IBSEISMICO Seismic Commercial B / 1 TRAVDOC Travel &Documentation B 1BUSLIC Business License B 5 of 5 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 C1TY OF Fax(408)777-3333 XPEkTINO Building Department JOB ADDRESS: , PERMIT# D ` i oc) OWNER'S NAME: i OA^ PHONE # 2�1 GENERAL CONTRACTOR: 5once C, 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 �U c�;n��2 S r S 27 Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date