09100112 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:.-4@j:;133MILLER AVE CONTRACTOR:DELTA ELECTRIC PERMIT NO:09100112
OWNER'S NAME: BOB SHERRY 724 COLLEEN DR DATE ISSUED: 10/19/2009
ER'S PHONE: 5863065355 SAN JOSE,CA 95123 PHONE NO:(408)224-0176
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class - -c.# 1 Z�1 I Z
MECH f- RESIDENTIAL f- COMMERCIAL
Contractor Date )d C1-{7
I hereby affi that 1 a lice ed under the provisions of Chapter 9 JOB DESCRIPTION:DUPLEX UPGRADE 2 SERVICES TO 200 AMP;
(commencing Section 7 0)of Division 3 of the Business&Professions DELTA
Code and that my license is full force and effect. ELECTRIC RENWD BUS LIC 10/19/09
1 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 Sq.Ft Floor Area: Valuation:$1500
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:36914020.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all no poi source regulation er the Cupertino Municipal Code,Section
9.18. Issued b Date:f ��f=
� .
Signature Date
\ C'14
L OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
1 hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
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, Signature of Applicant: Date:
Business&Professions Code)
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
1 hereby affirm under penalty of perjury one of the following three
HAZARDOUS MATERIALS DISCLOSURE
declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should 1 store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain c pliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health S fety Code, ections 25505,25533,and 25534.
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 Owner r author e a ent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
it nify and keep less the City of Cupertino against liabilities,judgments,
C and expense wh h may accrue agar st said City in consequence of the
granting of this p i Additionally,th plicant understands and will comply ARCHITECT'S DECLARATION
with all non-poin so rce regulatio s per he Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
5 ITEMS OF 10 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36914020 . 00
DATE ISSUED. . . . . . . : 10/19/2009
RECEIPT #. . . . . . . . . : BS000008957
REFERENCE ID # . . . : 09100112
10 q,
SITE ADDRESS . . . . . I11 MILLER AVE
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . :
OWNER BOB SHERRY
ADDRESS . . . . . . . . . . : 10211 MILLER AVE
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014
RECEIVED FROM . . . . : DELTA ELECTRIC
CONTRACTOR . . . . . . . : SANDY FRANKS LIC # 24971
COMPANY . . . . . . . . . . : DELTA ELECTRIC
ADDRESS . . . . . . . . . . : 724 COLLEEN DR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95123
TELEPHONE . . . . . . . . : (408) 224-0176
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 1, 500 . 00 1. 00 0 . 00 1. 00 0. 00
1BSEISMICR VALUATION 1, 500 . 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 327. 00 #5024
---------------
TOTAL RECEIPT 327 . 00
_,��- , CITY OF CUPERTINO
CITY Of
CUPEkTINO 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 "
HOA: Exterior work only) Yes ❑ No If es, provide letter from HOA
Owner's Name: Phone#:
Contractor: Phone: Z Z �-[—o i 7 �
-v-- L, ,A- e C-- Fax: - z o Z
Contractor License#: t{ Z C -17 Z
Cupertino Business License#: 7 j
Contact: Phone: 1-1`8 Y z q,5-07
-5 0'.0 Fax:
Residential El Commercial
n -c �o Zai A �
Job Description: Z v r Lr�tc �s
Lex V t'�'� Z S
Building Permit Info:
Bldg ❑ Elect El,--- Plumb ❑ Mech ❑
Type of Construction(Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B �L,13
Valuation: `f7DQ Square Footage:
Project Size: Express Lf--�Standard ❑ Lar e ❑ Ma'or ❑
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.buildit reen.or
Revised 07/14/09
CITY OF CUPERTINO
al- U-11
OF GENERAL BUILDING APPLICATION
CUPEI�TINO
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/masonry(includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
/ 1 MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit Fee P
IELCPLNCK 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 E/M/P) B
when not over counter) hourly-stand alone
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
j 1 TRAVDOC Travel &Documentation B
I 1BUSLIC Business License B
l 7
5 of 5
M.Indo-Dr Air Quality and Finishes
1.Use Low/No-VOC Paint 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes D
3.Use LowNo VOC Adhesives 3 IAQ/Health pts y=yes D
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes D
5.Use Engineered Sheet Goods wish no added Urea
Formaldehyde 61AQ/Health pts y--yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7.Sad fQF 4 IAOIHealth ots y:-yes _ D
B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes D
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes D
1 1 1
N.Fiooring
1.Select FSC Certified Wood Flooring B Resource pts y=yes 0
2.Use Rapidly Renenwahfe Flooring Materials 4 Resource pts y=yes D
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 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes D
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y-yes 0
1 1 1
Total Points Available: 1 1401 1301 57
Total Points Project Received: 1 01 0 —�
G:daWprogslgreenbuildingguidelineslremodalerslgreenpointsfina1212D4protecied.zls
Community Development
- 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
XPEI�TINO
Building Department
JOB ADDRESS: PERMIT #
x213 ,r 0
OWNER'SNAME: r1� PHONE # '-1 2 is-- s'o 7
GENERAL CONTRACTOR: -c L FAX # Z7 2 q - 3 O Z
I am not using any subcontractors: (7 -1 ?-o Cf
igna a Date
Please check applicable subcontractors and complete the followin 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
�j O er/Contractor Signature Date