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13090149-FP�� CITY Y OIF C>I,T]PlER'1< INO BUILDING DING ]P]ERM><T BUILDING ADDRESS: 10394 ORANGE AVE CONTRNCTOR:'9'Pi'B"Te-BE PERMIT NO: 13090149 ^err_ cr"ciWFD OWNER'S NAME: MAHAPATRA ABINASH AND VINJAMURI REM �l� Nf�la r DATE ISSUED: 09/18/2014 OWNER'S PHONE: 4084763814 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL CONSTRUCT DETACHED 2ND DWELLING UNIT (639 SQ /y /('f License Class Lic. # �/ / d ✓ FT). r Contractor 2k ro 1 /s7/7frC7 /,)'Date I hereby affirm that 1 am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions 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 Sq. Ft Floor Area: Valuation: $90000 rforntance of the work for which this permit is issued. ave 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 APN Number: 35719009.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT WORK IS NOT STARTLED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN P)C�� ISSUANCE Old to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 7ROMLASIT 180 DAB' CAILILIED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the / tS Issued by: Date: l granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. RE- ROOFS: Signature Date � All roofs shall be inspected prior to any rooting material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER- BUILDER DECLARATION Signature of Applicant: Date: hereby affirm that 1 am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1, 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 HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should 1 store or handle hazardous I have and will maintain a Certificate of Consent to self - insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this pen-nit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25505, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this /v / permit is issued. Owner or authorized agent: Date: 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 Compensation laws of California. If, after making this certificate of exemption, I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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, ARCHITECT'S DECLARATION costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date CITE' OF CUP ERTINO ]BUILDING ING PERMIT BUILDING ADDRESS: 10394 ORANGE AVE CONTRACTOR: CEVOLA CUSTOM PERMIT NO: 13090149 HOMES OWNER'S NAME: MAHAPATRA ABINASH AND VINJAMURI REM 832 CHYNOWETH CT DATE ISSUED: 09/18/2014 OW PER'S PHONE: 4084763814 SAN JOSE, CA 95136 PHONE NO: (408) 644 -4351 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL CONSTRUCT DETACHED 2ND DWELLING UNIT (639 SQ 7 License Class Lic. # qv; ; Lf FT). Contractor t Date Q q l e l j f`4 1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions 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 Sq. Ft Floor Area: Valuation: $90000 performance of the work for which this permit is issued. 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 APN Number: 35719009.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT ]EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN I8® �� ISSUANCE ®� to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 FDA M ]� ][,�� INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply b ate: / with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. RE- ROOFS: Signature (�y� _ Date J / 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 inspection. ❑ OWNER - BUILDER DECLARATION Signature of Applicant Date: 1 hereby affirm that 1 am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1, 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) 1, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534, 1 will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should 1 store or handle hazardous I have and will maintain a Certificate of Consent to self - insure for Worker's material. Additionally, should 1 use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District 1 performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25505, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this W ✓� f f Owner or authorized agent: - Date: permit is issued. I 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 Compensation laws of California. If, after making this certificate of exemption, I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct. 1 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, ARCHITECT'S DECLARATION costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date CUPERTINO CONSTRUCTION PERMIT APPLICATION. COMMUNITY DEVELOPMENT DEPARTMENT o BUILDING DIVISION 10300 TORRE AVENUE o CUPERTINO, CA 95014 -3255 (408) 777-3228 FAX (408) 777-3333 o building .euup rtino.ortf ME IMIT, In "111 0lb L 0\b �ao\ B n AI.TFRAT`l NN / TI n REVISTON /DEFERRED. ORIGINAL PERMIT # PROJECT ADDRESS 4. APN # of A� (1 ` 011, NAME PHONE E-MAIL 811V ASH A a STREET ADDRESS CrrY, STATE, ZIP FAX CONTACT NAME , PHONE E-MAIL b J STREET ��QR SS Ll /� /GENT SPATE, ZIP FAX ❑ OwNER 13 OWNER -Bur DER ❑ OWNER'A ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME / l < f' / G� LICENSE NUMBER Q LICENSE TYPE BUS. LIC # ' COMPANYNAME rU.Z. cu STOO -t A ®,�-t I<. S E -' 4 • C7 • !/O LA13 6C C,0,6s4 • Ive r FAX Ff '2 d (c( S- STREET ADDRfSS 3 2 C h ivo dv - T C_ CITY, STATE, ZIP '5 A, o S r 6 PHONE LE 6 3 S ARCIUTECVOE WEER NAME LWENSENUMBER SGS:LfC# COWANY NAME &MAIL FAX ST2EE'Y ADDRESS Crr'Y, STATE, ZIP PHONE JS " t EXISTINOUSE PRO POS USE CONSTIL TYPE # STORIES I USE TYPE OTC. SQFr. VALUA rIOtU (S) EXISTG AREA NEW FLDOR AREA DEITO AREA TOTAL NETAREA BATHROOM KITCHEN OTHER aE%WDEL AREA RFSR)DEL ABEA R63ffiD[L AREA PO DECK A HOETACR ATTACK #DWELLING UNITS: IS A SECOND UNIT YES SECOND STORY ❑ YES O I BENIGADDED? ND ADDITION? LINO PRE - APPLICATION ❑ YES IF YES, PROVIDE COPY OF WTHE BLDG AN OM AECEI Y; TOTAL V A r s r.. PLAN M"GAPPLO QNO APPROVALLETIEA 61CNLEBHOP914' O,NO �i it By my signature below, I certilfio, each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information f have provided is correct. f have read the Description of Work and verify it is accurate. ragree to comply with all applicable local ordinances and state laws relating buil g construction. representatives of Cupertino to enter the above- identifted property fort tioD purposes. t �1 Signature of Applicant/Agent: Date: .-- r SUPPLEMENTAL INFORMATIO Qi3lRED PLAN CHECK TYPE ROUTING SLIP ❑ OVER-THE-COUNTER _ New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building BUILDING PLAN REVIEW permit for new building, 1 EXPRESS PLANNING PLAN REVIEW _ Commercial BldgS: Provide a completed Hazardous Materials Disclosure STANDARD PUBLIC WORKS form if any Hazardous Materials are being used as part ofthis project. ❑ LARfE _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR �SANITARV submittal of Building Permit applicatiorL EWER DI STRICT ❑ ENVIRONMENTAL HEALTH BldgApp_201Ldac revised 06121111 M1 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION L11 ADDRESS: 10394 ORANGE AVE DATE: 09/20/2013 REVIEWED BY: Mendez APN: BP #: - VALUATION: 1$90,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY SFD or Duplex 2nd Unit? '' Yes No PENTAMATION 1 R3SFD2ND USE: PERMIT TYPE: WORK CONSTRUCT DETACHED GRANNY UNIT ON REAR OF SFDWL SCOPE OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID R -3 (Custom) II- B,111- B,IV,V -B 639 $2,577.00 IR3PLNCK $1,617.00 IR3INSP $0.00 PME Plan Check: $0.00 Permit Fee: $1,617.00 Suppl. Insp. Fee-.0 Reg. Q OT ro.01 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS: 1 639 $2,577.00 Construction Tax: IBCONST,I R $1,617.00 # new units NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc ). These fees are hosed on the nreliminary infnrmation available and are nnly an estimate Contact the Dent fnr addn'l info_ FEE ITEMS (Fee Resolution 11 -053 Eff. 711113) Xfech. Plan Check Plumb. Plan Check Elec. Plan Check rdfech. Permit Fee: Plumb. Permit Fee: Elec. Permit Fee: Other• ;4fec'h. Insp. Oilier Plumb Insp. Other Elec, Insp. Li Hech. Insp_ Fee: Plumb. brsp. Fee: F,lec'. Insp. Fee: NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc ). These fees are hosed on the nreliminary infnrmation available and are nnly an estimate Contact the Dent fnr addn'l info_ FEE ITEMS (Fee Resolution 11 -053 Eff. 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,577.00 Select a Misc Bldg /Structure or Element of a Building Suppl. PC Fee: Q Reg. Q OT 0,0 1 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $1,617.00 Suppl. Insp. Fee-.0 Reg. Q OT ro.01 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: IBCONST,I R 1 # new units $647.24 Administrative Fee: Q 0 Work Without Permit? 0 Yes 0 No $0.00 Advanced Planning Fee: IPLLONGR $89.46 Select a Non - Residential Building or Structure E) i Travel Doeutnenlution Fees: Strong Motion Fee: IBSEISMICR $9.00 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $4.00 SUBTOTALS: $4,943.70 $0.00 TOTAL FEE: 1 $4,943.70 Revised: 08101/2013 Building Department City Of'( upaullo f033))0 TNIC :V'e11UC Cupertino, CA 95014-3-255 Tcicphone: -,KN'-777-3)228 Fax: 4MS-777-3333 CONTRACTOR SUBCONTRACTOR LIST PERMIT 0 W, N F. R N1 A N-,l E: GENERAL 'ONTRACTOR: BUSINESS LIC[,*,NSf: ADDRLSS: 1.01W 0m, municipal Code re(plir"s sill business" working in I he cit.." to limo a City business Heells.o. NO BUILDING FINAI• OR !"VNAL OCCUPANCY INSPEC-1-10.N(S) NV.!(,i-- BE SCHEDULED UNTIL IHE GENERAL C(-)N1*R,;V—T()R AND AAA. SUBCONTRACTORS UAVE OBTAiNED ), CATY OF C'UPERTI'NO UCENSC. ........ .. . I all 1140t using ally subcontraclors: sign Dail Please check applicable subcontraclors and Complete the followhig! i0orniation: V ISUBCONTRACTOR 1 —H US NESS NIA A il F, RUSINE-SS LICENSE Cabilicts & N4 il lwork, [,.'learical Excavation Linoleum i Wood Glass li Glazillcy Heatinu fnsulaljon Masonry Painting 1, wallpaper Plumbing Roofin, Septic T",.nik Sheet Mctal Sheet: Rock Tile o tiler l'. onfratlor, Date PURPOSE: MANDATORY ffEMS COMMUNITY DEVELOPMENT DEPAf?TTaU4`L•17fN}G 01�/ISI,ON ALBERT SALVADOR, P.E., C.B.O., B� LL IGFF�A` 10300 TORRE AVENUE - CUPERTINO, CA 95014 - 3255 ; (408) 777 -3228 ^ FAX (408) 777 -3333 > buildingacupertino.org The 2010 CalGreen Code applies to all newly constructed hotels, motels, lodging houses, dwellings, dormitories, condominiums, shelters, congregate residences, employee housing, factory-built housing and other types of swellings with sleeping accommodations and new accessory buildings associated with such uses. Existing site and landscaping improvements that are not otherwise disturbed are not subject to the requirements of CALGreen. Project Name: 'yxPdC6: l� II IT��, Project Address: ompi4'r • Project Description: &twjr Instructions: 1. The Owner or the Owner's agent shall employ a licensed professional experienced with the 2010 California Green Building Standards Codes to verify and assure that all required work described herein is properly planned and implemented in the project. 2. The licensed professional, in collaboration with the owner and the design professional shall initial Column 2 of this checklist, sign and date Section 1 - Design Verification at the end of this checklist and have the checklist printed on the approved plans for the project. 3. Prior to final inspection by the Building Department, the licensed professional shall complete Column 3 and sign and date Section 2 - Implementation Verification at the end of this checklist and submit the completed form to the Building Inspector. Page t of 5 CalGreen 2010.doc revised 08127111 Column 2 Column 3 MANDATORY FEATURE OR MEASURE Project Verification Requirements »� PIA N. 1 N41 N, 0 ,; D Planning and Design - Site Preservation 4.104.1 A site plan and inventory of the site is developed and used to minimize site disturbance in order preserve desirable existing natural resources and minimize future adverse effects on the proposed structure. Planning and Design - Site Development 4.106.2 A plan is developed and implemented to manage storm water El drainage during construction. 4.106.3 The site shall be planned and developed to keep surface water away from buildings. Construction plans shall indicate how site grading or a drainage system will manage all surface water flows. Page t of 5 CalGreen 2010.doc revised 08127111 !Mff General 4.201.9 Low -rise residential buildings shall meet or exceed the minimum ® ❑ standard design required by the California Energy Standards. Moor Water Use 4.303.1 Indoor water use shall be reduced by at least 20 percent using one of the follow methods. ❑ Water saving fixtures or flow restrictors shall be used per Table 4.303.2. El El A 20 percent reduction in baseline water use shall be demonstrated per As of 7/01/2011 Table 4.303.1. 4.303.2 When using the calculation method specified in Section 4.303.1, multiple showerheads shall not exceed maximum flow rates. As of 7101/2011 4.303.3 Plumbing fixtures (water closets and urinals) and fittings (faucets and showerheads) shall comply with specified performance requirements. As of 7/01/2011 Outdoor !deter Use 4.304.1 Automatic irrigation systems installed at the time of final inspection shall be weather - based. Q Enhanced Durability and Reduced Maintenance 4.406.1 Joints and openings. Annular spaces around pipes, electric cables, conduits, or other openings in plates at exterior walls shall be protected El against the passage of rodents by closing such openings with cement mortar, concrete masonry or similar method acceptable to the enforcing agency. Construction !Taste Reduction, Disposal and Recycling 4.408.2 Where a local jurisdiction does not have a construction and demolition waste management ordinance, a construction waste management plan shall be submitted for approval to the enforcing agency. Building Maintenance and Operation 4.410.1 An operation and maintenance manual shall be provided to the building occupant or owner. Page 2 of 5 CalGreen 20I0.doc revised 08127111 A4.5 ENVIRONMENTAL QUALITY Fireplaces 4.503.1 Install only a direct -vent sealed- combustion gas or sealed wood- ❑ burning fireplace, or a sealed woodstove. Pollutant Control 4.504.1 Duct openings and other related air distribution component openings. ❑ shall be covered during construction. 4.504.2.1 Adhesives, sealants and caulks shall be compliant with VOC and ❑ other toxic compound limits. 4.504.2.2 Paints, stains and other coatings shall be compliant with VOC limits. ❑X ❑ 4.504.2.3 Aerosol paints and other coatings shall be compliant with product ❑X ❑ weighted MIR Limits for ROC and other toxic compounds. 4.504.2.4 Documentation shall be provided to verify that compliant VOC limit ❑ finish materials have been used. 4.504.3 Carpet and carpet systems shall be compliant with VOC limits. ❑X ❑ 4.504.4 Fifty (50) percent of floor area receiving resilient flooring shall comply with the VOC- emission limits defined in the Collaborative for High Performance ❑ Schools (CHPS) Low- emitting Materials List or be certified under the Resilient Floor Covering Institute (RCFI) FloorScore program. 4.504.5 Particleboard, medium density fiberboard (MDF), and hardwood plywood used in interior finish systems shall comply with low formaldehyde OX ❑ emission standards. Interior Moisture Control 4.505.2 Vapor retarder and capillary break is installed at slab on grade foundations. ❑X ❑ 4.505.3 Moisture content of building materials used in wall and floor framing is ^_j ❑ checked before enclosure. Page 3 of 5 CalGreen 2010.doc revised 08127111 indoor Air Quality and Exhaust 4.506.1 Exhaust fans which terminate outside the building are provided in every bathroom. Environmental Comfort 4.507.1 Whole house exhaust fans shall have insulated louvers or covers which close when the fan is off. Covers or louvers shall have a minimum ❑X insulation value of R-4.2. 4.507.2. Duct systems are sized and designed and equipment is selected using the following methods: 1. Establish heat loss and heat gain values according to ACCA Manual J or equivalent. 2. Size duct systems according to ACCA 29 -D (Manual D) or equivalent. 3. Select heating and cooling equipment according to ACCA 36 -S (Manual S) or equivalent. INSPECTOR INSTALLER AND SPECIAL Qualifications 702.1 HVAC system installers are trained and certified in the proper installation of HVAC systems. 702.2 The Licensed Professional responsible to verify CALGreen compliance is qualified and able to demonstrate competence in the discipline they inspect ❑X and verify. Verifications 703.1 Verification of compliance with CALGreen may include construction documents, plans, specifications, builder or installer certification, inspection reports, or other methods acceptable to the enforcing agency which show substantial conformance. Implementation verification shall be submitted to the Building Department after implementation of all required measures and prior to final inspection approval. 4 of 5 CalGreen 2010.doc revised 08127111 CAILGREEN SIGNATURE DECLARATIONS Project Name: A91WAY ; Project Address: l0�5 91/ 4%M1 J419 xz Project Description: s5UAV 4WYG1% -V4 , Complete all lines of Section 1 — "Design Verification" and submit the completed checklist (Columns 1 and 2) with the plans and building permit application to the Building Department. The owner and design professional responsible for compliance with CalGreen Standards have revised the plans and certify that the items checked above are hereby incorporated into the project plans and will be implemented into the project in accordance with the requirements set forth in the 2010 California Green Building Standards Code as adopted by the City of Cup in o. 8�� ®12-014 Owner's Signature 4Rz ;Y14;>f gj wppo Owner's Name (Please Print Design Pfofessional's Signature Design Professional] .Kame (Please Print) of License Professional responsible for CalGreen compliance Name of License Professional responsible for CalGreen compliance (Please Print) Email Address for License Professional responsible for CalGreen compliance SEC CAN F''L E TAT OO E�IFICAI ON Date ® 'b[ ®s° j ;g Date ® 6/165 D ate 09961°of7�7 Phone Complete, sign and submit the competed checklist, including column 3, together with all original signatures on Section 2 to the Building Department prior to Building Department final inspection. have inspected the work and have received sufficient documentation to verify and certify that the project identified above was constructed in accordance with this Green Building Checklist and in accordance with the requirements of the 2010 California Green Building Standards Code as adopted by the City of Cupertino. Signature of License Professional responsible for CalGreen compliance Date Name of License Professional responsible for CalGreen compliance (Please Print) Phone I Address for License Professional responsible for CalGreen compliance Page 5 of 5 CalGreen_2010.doe revised 08 /27/11