10080181CITY OF CUPERTINO BUILDING PERMIT
ILDING ADDRESS: 21599 EDWARD WAY
VNER'S NAME: KAREN CHIU
NER'S PHONE: 5103322652
LICENSED CONTRACTOR'S DECLARATION
:erase Class Lic. # s5s i ` Q `
atractor �C��Date
rereby affirm that I am licensed under the provisions of Chapter 9
ommencing with Section 7000) of Division 3 of the Business & Professions
ode and that my license is in full force and effect.
CONTRAC''OR: SANDIUM
hereby affirm under penalty of perjury one of the following two declarations:
have and will maintain a certificate of consent to self -insure for Worker's
ompensation, as provided for by Section 3700 of the Labor Code, for the
erformance of the work for which this permit is issued.
have and will maintain Worker's Compensation Insurance, as provided for by
ection 3700 of the Labor Code, for the performance of the work for which this
ermit is issued.
APPLICANT CERTIFICATION
certify that I have read this application and state that the above information is
;orrect. I agree to comply with all city and county ordinances and state laws relating
o building construction, and hereby authorize representatives of this city to enter
,ipon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep hannless the City of Cupertino against liabilities, judgments,
-osts, 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 Coder, Section
9.18. 7.010
� ^ . � � M, Date
Signature
RE -ROOFS:
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
t f om the Contractor's License Law for one of inspectic n.
4223 VERDI GRIS CIR
PERMIT NO: 10080181
DATE ISSUED: 08/26/2010
SAN JOSE, CA 95134 I PHONE NO: (408) 894-9072
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
MECH r RESIDENTIAL r COMMERCIAL r
JOB DES,�RIPTION: FURNACE REPLACMENT, ADD A/C INSTALLATION
Sq. Ft Flo, r Area:
Valuation: $5000
Occupancy Type:
APN Number: 35619008.00
PEIMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYSOF
CARL ED INSPECTION.
IT ISSUANCE OR
180 DAYS FROM LA
Date:g )-Ll
Issued by:
I hereby affirm that I am exemp r
the following two reasons:
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,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
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
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
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
me subject to the Worker's
not employ any person in any manner so as to beco
Compensation laws of California. If, after making this certificate of exemption, I
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.
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
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
, and expenses which may accrue against said City in consequence of the
ging of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Date__
Signature
Signatur: of Applicant:_
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compli trice with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additb rnally, should I use equipment or devices which emit hazardous air
contandnants as defined by the Bay Area Air Quality Management District I will
maints in compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Healtli & Safety Code, Sections 25505, 25533, and 25534.
Ow r horized agenk Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lend:r's Address.
ARCHITECT'S DECLARATION
I and �rstand my plans shall be used as public records.
Lice ►sed Professional.
*a. iv
CI of
CUPEkTINO
CITY OF CUPERTINO
FURNACE/AC
PERMIT APPLICATION FORM
APN # r
Date: %
Building Address: i
z I C) v
Owner's Name: Via- a
Phone #: b 24�S
Contractor:
Phone #: 44 S'qLE 7o'7 -z-
Fax #:
Fax
Contractor License #:
Cupertino Business License #:
00
Contact:
Phone #:41 8N io? Z
Fax #:
Building Permit Info:
Elect Plumb ❑� Mech
Residential (:ommercial LJ
Job Description:
For Residential Installations:
Attic F-11 Sc floor ❑ 2"d floor El
Adhere to minimum setback re uirement ,�
For Commercial Installations:
Replacement same weight ❑ Adc.itional weight (structural calcs) ❑
Structural Calculations required for new installation C1
New installation Planning Approval Required ❑
Cost of Project: Type of ConstnLction (Usage Class):
Strapped On Platform JZ Bonded New Location Replacement
Project Size: Express ❑ Standard ❑ Large ❑ :vlajor ❑
Valuation:
4Saa0
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include vi plan set & the sheet index.
Revised 01/07/09
CITY OF CUPERTINO
N2
FEE ESTIMATOR - BUIILDING DIVISION
ADDRESS: DA"CE: REVIEWED BY:
.CPN: BP#: `VALUATION: 1$5,000
I � IUMT "I Y PE: Mechanical Permit PLAN CHE 2K TYPE: Alteration /Addition./ Repair
N1 ;R), i, r ; ;, PENTAMATION
SFD or Duplex I l (i; i1 -; k'i_, PERMIT TYPE:
h: / EQUIP TYPE FEE ID
(<=10K cfm) IBREMAIR
F . F -)reed-Air 1MFR=<100
TOTALS:
.I"
hrs $0.00 ;ultl I'icrn %r,i'�
'"ch. Permit Fee: IMPERMIT
hrs $42.00
Cc
N.a /tan/ far addn'l info.
T1.
1 RMAP2
,("s "re owe" an snc r c.wr"r.". ......
h'ee Resolution 09-051 Eff ,/l:'ll))
rr................».,...
FEE
_. ... - .
oTY/FEE
- -- -- -
MISC ITEMS
$0.00
$189.00
.
$42.00
F-71
omit? 0 Yes E) No
$0.00
A
.!ation Fee: ITRA VDOC
$42.00
Select an Administrative Item
';ission Fee: IBCBSC
$1.00
S[IBOTAs:'
$274,001
$0.00TU'A Fes•'
yam.
$274.00
Revised: 8/17/2010
1. 19 set_OW)NO-W)cPow#
1 IAQ/-lealth pts
yges
2. Use Low VOC, Water -Based Wood Finishes
2 IAQ/iealth pts
y --yes
3. Use WOW VOC Adhesives
3 IAQ/-lealth pts
y --yes
4. Use Salvaged Materials for Interior Finishes
3 Resource pts
yeses
5. Use Engineered Sheet Goods with no added Urea
4 Rescurce pts
y=yes
Formaldehyde
6IADMealth pts
y --yes
6. Use Exterior Grade Plywood for Interior Uses
1 IAQiHealth pis
y --yes
7,Sse1A+4tARF _ _ _ .-.
-_ _ 4 IAQ Health -pts y=yes
B. Use FSC Certified Materials for Interior Finish
4 Res )urce pts
y --yes
9. Use Finger -Jointed or Recycled -Content Trim
1 Res )urce pts
y --yes
10. Install Whole House Vacuum System .
3 IAC Mealth pts
y --yes
N. Flooring
1. Select FSC Certified Wood Flooring
B Resoires pts
yeses
fi4wE 13* floodrg Matenms
4 Resc irce pts
y --yes
3. Use Recycled Content Ceramic Tiles
4 Resc irce pts
y --yes
4. Install Natural Linoleum in Place otVinyl
5 IAQ/-lealth pts
y --yes
5. Use Exposed Concrete as Finished Floor
4 Rescurce pts
y=yes
6. Install Recycled Content Carpet with Low VOCs
4 Rescurce. pts
y --yes
Total Points Available:
Total Points Project Received:
1401 130 57
0 0 0
G:data/pro*greenbdcln;guidelinesiramodelereJgreenpointdnat21264pntaDtedxls
CUPERTINO
CONTRACTOR/ SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS: 2
PERMIT #610 <F, D
—41
OWNER'S NAME:
GENERAL CONTRACTOR:
PHONE # O 33Z 2652
BUSINESS LICENSE #
ADDRESS:
CITY/ZIPCODE:
*Our municipal code requires all businesses 4vorking in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSI ECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SU ONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. <
Q
1 am not using any subcontractors: ZG Zo ( p
Signatu re Date
Please check applicable subcontractors and complete the following information:
L
Owner / Contractor Signature
Ylw/Lc)
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
L
Owner / Contractor Signature
Ylw/Lc)
Date