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09100093 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19160 TWIG LN CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO:09100093 OWNER'S NAME: GENE LESLY DATE ISSUED: 10/15/2009 NER'S PHONE: 4082576916 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT f— f— PLUMB License Class G`�"� G �i # ��W `D l� � C MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am license 'Ander the provisions of Chapter 9 JOB DESCRIPTION:REPLACE WATER HEATER AND WALL (commencing with Section 7000)of Division 3 of the Business&Professions FURNACE;GREG BELLOWS Code and that my license is in full force and effect. PLUMBING INC.PD FOR BUS LIC 10/15/09 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 Sq.Ft Floor Area: Valuation:$3400 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:37508021.00 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 non-poi t source re�ions per Zj e Cupertino Municipal Code,Section 9.18. Issued by: Dater � Signature � Date /Dh(oC LJ OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that 1 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. 1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the stricture 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 constrict 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 HAZARDOUS MATERIALS DISCLOSURE declarations: I 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 I 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 compliance 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&Safety Code,Sections 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,I Ow er or autho t: Date: l0 `y O� 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. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a constriction 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 inify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 37508021 .00 DATE ISSUED. . . . . . . : 10/15/2009 RECEIPT #. . . . . . . . . BS000008923 REFERENCE ID # . . . : 09100093 SITE ADDRESS . . . . . : 19160 TWIG LN SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER GENE LESLY ADDRESS 19160 TWIG LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : GREG BELLOWS PLUMBI CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096 COMPANY TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 3, 400 . 00 1 . 00 0 . 00 1 . 00 0 .00 1BSEISMICR VALUATION 3, 400 . 00 0 .50 0 . 00 0 . 50 0 .00 1BUSLIC FLAT RATE 1. 00 114 .00 0 .00 114 . 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 1PRWHEATR UNITS 1. 00 25 .00 0.00 25. 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 329 .50 0 . 00 329. 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 329.50 --------------- TOTAL RECEIPT 329 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CUPERTINO 00 C9 FURNACE/AC CUPEkTiNO PERMIT APPLICATION FORM APN # 0 ' Date: �0//s o Building Address: IN 6414 rmo `�IS6 111L Owner's Name: Phone#: Contractor: Phone#: q.2 i L� & �7 �1 �t,�% 1 (;l C_., Fax#: Contractor License#: Cupertino Business License#: q00 1 Contact:,, \ � Phone#: _ �- 7- �• � Fax #: Building Permit Info: Elect ❑ Plumb Mech Residential Commercial ❑ Job Description: 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): u� Tt 170 3 o y, Strapped ❑ On Platform Bonded El New LocationEl Replacement Project Size: Express ❑ 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. 6— Revised 01/07/09 CITY OF CUPERTINO a,--- FURNACE/AC CUPEkTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1MRAPPVNT Residential for the install/relocate/or M replacement of ea appliance vent install &not incl in an appl permit. FURNACE FURN/AC 1 PGASRES Residential for ea gas piping system of P 1-4 Outlets 1 BPGAS 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 1 MECPLNCK Mechanical Plan Check M 1MFR=<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 1 EPERMITFEE Electric Permit Fee E / 1MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE Plumbing Permit P 1 TRAVDOC Travel Documentation B 1BUSLIC Business License B INPUT Resources • IAO/Health M. n oor Air ua ity and r mts es 1.Use Low/No-VOC Paint 1 IAQ/Health pts y=yes D 2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0 3.Use Low/No VOID Adhesives 3 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 61AQ/Health pts y=yes 0 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0 7.Seal all Exposed Particleboard or MDF 4 IAQ/Health. pts y=yes 0 8.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0 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 LO 0 1 i 1 N.Flooring 1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0 2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 0 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 0 6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0 1 1 1 Total Points Available: 1 1401 130 57 Total Points Project Received: 0 0 0 G:data/progs/greenbuildingguidelines/remodelers/greenpointsfinat2.12.04protected.xis y Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 ,,.-UPEKTINO Building Department JOB ADDRESS: ) 1 60 bJ PERMIT # 0 l 0q OWNER'S NAME: ! ` PHO _ GENERAL CONTRACTOR: FAX # �� I am not usingany subcontractors. C Sigrikure Date Please check applicable subcontractors d 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 Sheqt Rock Tile ner Contractor Signature Date