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09080121 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21703 CASTLETON ST CONTRACTOR:PALOMO CONCRETE PERMIT NO:09080121 OWNER'S NAME: AMY PING MA P O BOX 282 DATE ISSUED:08/13/2009 C, ER'S PHONE: 4082347578 MORGAN HILL,CA 95038 PHONE NO:(408)968-0107 0 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG T_ ELECT r PLUMB rµ License Class Lic.# MECH r- RESIDENTIAL COMMERCIAL Contractor _Date hereby affirm that 1 am licensed under the provisions of Chapter 9 .LOB DESCRIPTION:FILL THE SWIMMING POOL,REPLACE WITH (commencing with Section 7000)of Division 3 of the Business&Professions GRASS LATER. Code and that my license is in full force and effect. 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. Sq.Ft Floor Area: Valuation:$4500 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 permit is issued. APN Number:35618067.00 Occupancy Type: APPLICANT CERTIFICATION I certify that 1 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnity and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. 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 Issued Date: 9.18. `3 Signature Date y roofing ROOFS: Kk� OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection,I agree to remove all new materials for affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). 1 hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: 1 have read the hazardous materials requirements under Chapter 6.95 of the 1 have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this 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 permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. 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 0 ''�'eH�l rizet �Q Compensation laws of California. If,after making this certificate of exemption,I %% �` t' Date: 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 I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address u'- he above mentioned property for inspection purposes.(We)agree to save i 6f)-and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION cows,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the 5 pertino Municipal Code,Section 9.18. /' Licensed Professional Signature_,_<_�__ Date ( � G 0��80LA CITY OF CUPERTINO DEMO CUPEkTINO PERMIT APPLICATION FORM APN#�.�CP �, © ca O Date: 0 13 lay Building Address: - -7� / /y C, . Mailing Address (if different from building address): Owner's Name: PPhone: w Contractor: Phone : `' Pa IC m0 6 c- o /0 Fax: Contractor License #: 7ZO3 Cupertino Business License #: Contact: qe clyy- /tea t0 m v Phone: Fax: Residential [ Sq Footage W-9 Hoc st commercial ❑ Sq Footage Job Description: 5hIrnRrW, Y�SS fir � rQ zw" y Valuation: f Gt tt'k-7 a> '_-py ` cam 0v-t Project Size: Express ❑ Standard [� Lzrge ❑ Major ❑ Please complete relevant portions of the Green Building Checklist & attach it to the application or if applicable, include on the plan set & the sheet index. Quantity Fee ID Fee Description Fee Group Permit Type 1DEMORES Demo-Residential B 1SFDWL-DEM 1DEMOPRES Pool Demo Residential B 1SFP00L-DEMI r 1BCBSC Cal Bldg Standards B ALL PERMIT Commission Fee TYPES I 1BSEISMICRE Seismic Residential B Revised 01/07/09 ;,ENTER PROJECT NAME v S � Enter description here,and enter points available for measure In appropriate categories b Dre right 0 0 0 Enter description here,and ender points available for measure In appropriate categories to tine right Enter description here,and enter points available for measure In appropriate e111e00rias to he right 0, U 0 Enter description here,and enter points available for measure In appropriate categories to the right 4.Innovation:List innovative measures that most the green building objet Ives of the Guidelines.Enter up to a Build It Green Checklic_ts and rid-lin.c maximum combined total of 20 pts.See Innovation Checklist for suggested measures,using the link to the right. Innovation In Community:Enter description here,and enter points available for measure in appropriah calagories to the right 0 0 0 V 0 0 0+ Innovation in Energy:Enter description here,aro enter points available for measure In appropriate cal igories to the right 0 0�» D^r 0� 0 0 Innovation In IAOIHealth:Enter description hare,and enter points available for measure in appropriate categories to the right 0 �0� 0. 0 y D: 0 Innovation In Resources:Enter description here,and enter points available for measure In appnoprlah categories to tie right YY0 0_ D 0' 0 0r Innovation in Water:Enter description here,and enter points available for measure In appropriate tate Tories to the NhL 0 _ 0 YO v! 0.° D Total Available Points h Other=4 0 TME l Available Points in Specific Categories' 4+ 96+ 42+ 66+ 43+ MinimL m Points Required in Specific Categories 0 30 5 6 9 otal Points Achieved 1 I I 1 I 1 Project has not yet met the following recommended minimum requirements: - Total Project Score of At Least 50 Points -Required measures: -A3a: 50%waste diversion by weight -I2: 15%above Title 24 -N1:Incorporate Green Point Rated Checklist into blueprints r -Minimum points in specific categories: -Energy(30 points) IAQ/Health(5 points) -Resources(6 points) -Water(9 points) 0 2DO7 Build It Green Single Family GreenPc int Checklist 2DD7 Version Page 7 of 7 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 .MkTINO Building Department JOB ADDRESS: Z,70 3 6qs� S PERMIT # v �l OWNER'S NAME: - m o.. PHONE # 2 `'r— -7S 7 GENERAL CONTRACTOR: Y7Tj FAX # Pck o M o Coll cr.&(z I am not using any subcontractors: Si;nature 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