09070204 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10238 RI&WOOD DR CON'T'RACTOR:TBD-TO BE DETERMINED PERMIT NO:09070204
OWNER'S NAME: FAUCETT JOHN W AND DELORES A DATE ISSUED:07/30/2009
!;R'S PHONE: 4082573394 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH T_ RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 J OB DESCRIPTION:UPGRADE ELECTRICAL PANEL FROM I OOAMP
(commencing with Section 7000)of Division 3 of the Business&Professions TO 200AMP
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. q,Ft Floor Area: Valuation:$1700
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. f.PN Number:36908026.00 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 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
indemnify 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. �4y
Signature Date _
RE-ROOFS:
OWNER-BUILDER DECLARATION ill roofs shall be inspected prior to any roofing material being installed.If a roof is
i istalled without first obtaining an inspection,I agree to remove all new materials for
1 hereby affirm that I am exempt from the Contractor's License Law for one of i ispection.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, �ignature 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).
I 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 1 store or handle hazardous material.
1 have and will maintain Worker's Compensation Insurance,as provided for by iWditionally,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. l lealth&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'sw r a itl ori ed agent
Compensation laws of California. If,after making this certificate of exemption,I "^ 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 1 have read this application and state that the above information is bender's Name
correct. 1 agree to comply A ith all city and county ordinances and state laws relating
to building construction,mid hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
it 'iify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
c� 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 Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
nIQ0-70.�;Lc--�L4
r CITY OF CUPERTINO
CUPERTINO GENERAI. BUILDING
PERMIT APPLICATION FORM
APN# Date:7/30 A>
� 3 (-Ao 9
Building Address:
It H
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of thi,; project? Yes ❑ No
HOA: Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA
Owner's Name: Phone#:
Contractor* Phone: q o V - 3 v j - 2"w 3
l m_a Fax:
Contractor License#: 7 5 B 2
Cupertino Business License#:
Contact: _� Phone:
Fax:
Residential Commercial
Job Description-
p,/ �1 N _F ,V7" /Old Ater 2,f�v- A-mll
LL f d'
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-:3
Valuation: v Square Footage:
Project Size: -Express ❑ Standard ❑ Large I] 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.builditer�,-en.or
Revised 07/14/09
CITY OF CUPERTINO
CITY 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
1WINREP Replacement windows/sliding glass B
door (ea ,") windows)
1WINMEWSTR New Win,low- shear B
wall/masc my(includes plan ck fee)
IEPERMITFEE Electrical Permit Fee E
IMPER.MITFEE Mechanical Permit Fee M
1PPER.MITFEE Plumbing Permit Fee P
1 ELCPLNCK Stand Alc ne Electric Pln Ck(hourly) E
1 MECPLNCK Stand Alc ne Mechanical Pln Ck(hrly) M
1PLMBLNCK 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) hourl -stInd alone
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
I 1TRAVD0C Travel &Documentation B
1 1BUSLIC Business License B
5 of 5
M.Indoor Air Quality and Finishes INPUT Resources Energ� IAD�Healfh
1.Use Lftwft"VOG PaM 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3.Use Lowi%VOC Ad4*es 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
0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes
7.Seal all brosedParWaboarldor F 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 0
N.Flooring
1.Select FSC Certified Wood Flooring E Resource pts y=yes 0
2.Use Rapidly Renewable Flooring Materials , Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles L Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl i IAQ/Health pts y=yes 0
5.Use Exposed Concrete as Finished Floor e Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs Resource pts y=yes 0
Total Points Available: ( 1401 1301 57
Total Points Project Received: �" 01 01 0
G:data/progs/greer buildingguidelines/remodelers/greenpointsfinal2.12.D4protected.xls
CITY OF =ERTINO
5 ITEMS OF 12 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot :
APN 36908026 . 00
DATE ISSUED. . . . . . . : 07/30/2009
RECEIPT #. . . . . . . . . BS000008315
REFERENCE ID # . . . : 09070204
SITE ADDRESS . . . . . : 10238 RICHWOOD DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER FAU"-ETT JOHN W AND DELORES A
ADDRESS 10238 RICHWOOD DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3361
RECEIVED FROM . . . . : JOHN W FAUCETT
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 1, 700 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 1, 700 . 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 423 .40 #325
---------------
TOTAL RECEIPT 423 .40
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
4XPEkTINO
Building De zutment
JOB ADDRESS:! �9�Uiy PERMIT #
)00j �-T6` Z� -Z-0
OWNER'S NAME: PHONE # 2-�r 7— 33` v
GENERAL CONTRACTOR: FAX#
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and cornAete 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