09020011 (2)PERMIT # 09 6 2 0 ll DATE „ 2
PROJECT 4, k--�X s
ADDRESS
APPLICANT MARle,,1 t//I /, k OWNER �4,1n �, 9 m �9 � Y/ 2)
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APN# S% 6131 Z ICES. (LVNG) zu / (GARAGE)
COMM. SQ. Fr. (NEW) T.I. SQ.F.
II RES. REMODEL ZZL2
CONTACT /j'1C�/z7�� /c/q / PHONE# `10S' 7LIl 3yy6 FAX %Y1—,5e570 ;
Xl9
VALUATION (Cost f Project)
NOTES:
REQD. PAID
CONSTRUCTION TAX (Y)
(I)
SCHOOL FEES (Y)
(N)
HOUSING MITIG (Y)
(N)
HEART OF THE CITY (Y)
(N)
ISSUED B DATE %/ O ;' TOTAL FEES
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BUILDING DIVISION
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BUILDING ADDRESS:
10327
OWNER'S NAME:
408) 741-3
PERMIT NO.
FERMrr ISSUE DATE
CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG EL.ECr PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm am I am licensed under provisions of Chapter 9 (commencing
vit h Section 7 f Di on 3 of the Business and Professions Code, and my license is
n full force m Y c
',Icerae Gass Lk. 0 7 7
)ales '^ a Contractor i.M&J aiv /'v.
Cm7ECrS DECLARATION
I understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
'ollowing reason. (Section 7031.5, Badness and Professions Code: Any city or county
which requites a permit to ctmstrum alter. improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
drat he is licensed pursuant to the provisions of site Contractors Lirxnse Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 703 M by arty applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
❑ Las owner of tlse property. or my employees with wages as their sole compensadon,
will do the work and the structure is not intended or offered for Salo (Sec. 70". Business
and Professions Code The Contactors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not interceded or offered for sale If.
however, the building or improvement is sold within one year of completion. the owner -
builder will have the burden of proving that he did rot build or improve for purpose of
Side.).
❑ L as owner of the property. am exclusively contracting with licensed contractors to
construct the project (Sec 7044. Business and Professions Code.) The Contractors Li -
cease Law does not apply to an owner of property who builds or improves thereon, and,
who contracts for Such projects with a contacwr(s) licensed pursuant to the Contactors
I scene Law.
❑ I am exempt under Sec B & P C for this reason
owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affhm under penalty of perjury one of the following declantiomt
❑ 1 hate and will maintain a Certificate of Consent to self -Insure for Workers Compen-
sation, 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 Workers Compensation Insure rta, as required by Section
3700 of the Labor Code, for the performance of the worst for which this permit Is issuert
My Worker's Compensation Insurance tamer Policy number ass:
Carrier. N: •fLfitt'i1 ,rtS�"x.+vl' � Bcy Na: U272
CERTIFICATE OF EXEMPTION FROM WORKERS'
D / lnQ� (JC' iL COMPENSATION INSURANCE
i (iTt7s sxU�tt L9- trot be completed if the permit is for one hundred dollars ($100)
or leas)
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 Workers' Compensation
Laws of California. Due
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the tabor Cod,, you must
forthwith comply with Such provisions or this permit shall be darted revoked.
CONSTRUCTION LENDING AGENCY
I hcmby affirm that them is s construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097. Civ. C.)
Lenders Name
Lenders Address
I certify that 1 have read this application and state that the above information is
comet I agree to comply with all city and county ordinances Lad state laws relating to
building construction, and hereby authorise mpresentadves of this city to enter upon Use
above -mentioned property for inspection purposes
(We) agree o ere. indemnify and harmless site City of Cuprnino against
liabilities, jndgmen ors and expenses w may lo any rosy accrete against said City
in consegtrerce of ling of this t
APPLICANT U STANDS A 1 COMPLY WITH ALL NON -POINT
SOURCE REG ONS.
Signature of p rantlCon Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fuutc building occupant sore or handle hrmrdous material
as defined by tic Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(a)7
❑Yes No
Will the applicant or turc building occupant use equipment or devices which
emit hazardous air contsmirsn defined by the Bay Area Air Quality Management
District?❑ Yes A o _
1 have trod r
materials rcquimrro un r Chapter 6.95 of the Califor-
nia Health a Safests 25505.25533 534 undcrssnd that ifthe building
does rot hthat it is nsibil' y o notify the amhpant of the
requhemen h prior o o hcalc of Oqupsoyy. ,r,
Job Description
ADD 189SQ,BREAKFAST RM,EXTENSION OF KITCHEN &
1187SQ MSTRBDRM, BATH, BATHROOM2-NO RE -ROOF & NO
STRUCTURAL
Sq. Ft. Floor Area Valuation
100000
APN Number Occupancy Type
32613121.01
,t?
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date 2-
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.
Signature of Applicant Date
All roof coverings to be Class'n" or better
Date
CUPEI�TINO
CITY OF CUPERTINO
ADDITION/REMODEL
PERMIT APPLICATION FORM
APN # n � i � t � [
oc I V
Date:
Building Address: k 03 2l v; %' ^ k 0 L� t l-v ts
Mailing Address (if different from building address):
Owner's NaN : � �^ � I o 1 � SO
Phone # : _ ( l 0( _ 80O �
Contractor: -T ; 1� g t ; N.t D 1? �; G
Phone #: 106 _ -7 4 1 _ 3 o d o
Fax #:
Contractor License #: 5 q 0 -j
Cupertino Business License #: 22 3l�9 0
Contact: MAR wp,(,l C
Phone #: q ob _ 7q-I - 3o do
Fax #:
Building Permit Info:
Bldg. Ef Elect. Plumb. 2� Mech. Hillside ❑
Job Description:
Addition -What is being added?(Be Specific):
0i SQ 1 • t3 k,E_�
Hef ,,i
What is being remodeled (not including addition)?
1 S-7 5Q • rT
Remodel Includes Re -Roof. Yes No [� If yes list number of squares
Remodel Includes Structural: Yes No ❑ C t✓
Do you have the pre -application planning approval? Yes ❑ No
If yes, please provide a copy of your planning approval letter. Planners name:
Square Footage:
Addition: I 9>1 Porch: Deck: Garage: Detached Attached
Remodel: Kitchen40%VBath lf661 Other kA-b-LG(-1- 1?bCD (Zoa-(-4 � f?AT14
Type of Construction (Usage Class):
Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ IUIII B, IV -HT, V-B E!f
P- -�
Valuation: 100 00 0D
Please chec this box if the project is a
(d
second -story addition ❑
Project Size: Ex ress [!f Standard ❑ Large ❑ Major ❑
Please complete relevant portion of the Green Building
Checklist & attach it to the application or if applicable,
Green Building Points Achieved:
include in plan set & the sheet index.
***For Office Use Only***
Over -the -Counter ❑
Revised 01/07/09
41TY
CUPERTINO
CITY OF CUPERTINO
ADDITION/REMODEL
FEE SCHEDULE
Quantity
Sq Ft
Fee ID
Fee Description
Fee Group
Permit Type
ADDITIONS
1R3SFDADD
PLLONGRNGR
Long Range
Planning/Residential
PL
/
1 R31NSP
Dwellings Inspections
B .
1R3PLNCK
Dwellings plan check
B
1 R3REPINSP
Dwellings Repeat
Inspection
B
1 R3REPPLNC
Dwellings Repeat Plan
Check
B
1R3HINSP
Dwellings Hillside
inspection
B
1 R3HPLNCK
Dwellings Hillside plan
check
B
1R3HREINSP
Dwellings Hillside
Repeat Inspection
B
1R3HREPLNC
Dwellings Hillside
Repeat Plan Check
B
1R3ALTINSP
Dwellings Alternate
Materials Inspection
B
1 R3ALTPLNC
Dwellings Alternate
Materials Plan Check
B
1PCESS
Cesspool
P
1PPRSEWG
Ea. Private Sewage
Disposal System
P
1PRSEWER
Sewers
P
113PSPRINK
Lawn Sprinkler/Backflow
P
1BPWSVCS
Main Water Service
P
1
J
1BCBSC
Cal Bldg Standards
Commission Fee
B
ALL PERMIT TYPES
1 BSEISMICRE
SeismicResidential
B
1RER00FRES
Residential Re -roof Each
100 SF
B
CITY OF
CUPEI�TINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
1032 Vr S A
PERMIT #
og(92-0c)
OWNER'S NAME: 5A AW-ii MA ( S
PHONE # v - /
GENERAL CONTRACTOR: 7 Afp_W- l Sl N
FAX # 0c3 - 7W — v
I am not using any subcontractors:
Signature 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
(J,�.k 04C&----- V 2/ 2�
er/Contractor Signature Date
Nov 09 09 03:11 p
p.1
1'1/09/2009 12:02 4087413007 1IMLL
����4/0
INSTALLATION CERTIFICATE I of I F-6R
Site Address
"Ity
Permit }ti/'� I
(o/
Installation cartificates (CF-6R) are required %r each and CYCt7 dwelling unilr when-ir+stanation oftaeasuros that regttive
field verification and diagnostic testing it complete, the builder or th0 bmlda's wbcantractw shall cvmpkte dieposdc
testing and tbo procedures specified in :hie section. When chin irs;tal7ation is complete, the builder or the builder's
subcontractor shall complete the CF- iR (Installation Cudficste), and keep it at ttto building site for TtviCw by the building
departntcaL The builder also shall provide it copy of the lWWJatioe Ccrtifioato to the HERS rater far sty nuasures requiring
field verifiiattfon and diagnostic testbta. par Section 10-1 03a�).
• : r�:.r . r1 � lt�►u
Mli��
lll�ii�■rli�r�s■■li�
�l��f>'.'�I
t��■s■s>ral♦I
1 For shun gas storage (rained input of lass than or equal to 75,000 Btvlbr� elVewAle resistance and cheat pump water
batters, list Energy Factor (EF). For large Da storage water beaters (rated inpvt ofgcater than 75,000 El tt/hr), list
Recovery (?,E). Thermal Efficiency, Standby Loss and Rated ]Input. For instantaneous pa water heaters, list Thermal
EfficicrKy arW Rated Input.
2. R-lit external insulation is mandatory for stmag4 wdcr heaters with an enera factor of ices than 0.59.
Kitchen P*tnC:
If indicated on the CF-1 R, all hot wear piping? 314 inches in diameter that runs from the hot weer source, to the kit-hm
fixtures is insulated.
)Rnueefs & Sbower Heads:
All Fducets and showerheads installed we certified to the Energy Commission, pursuant to Title.24. Part 6, Section 11 I.
Central Watt' Heming in Ralldiagx with Multiple Dwelling Units (required for prescript(ve)
❑All bet water piping in main circ"ng loop is insulated to requirements of §150(j)
❑Central hot water systams serving six or fewer dwelling units which have (1) less than 25' of distribution piping
outdoors; (2) uro disG'ibution piping wWcrgrand; (3) no recirculation pump; and (4) insulation an distribution piping
that meal the requiranents of Section 1.300)
❑Central hot water systems carving more than 6 dwelling units - presence of eitftcr a time control or a time,"perantre
control
❑ i, the arukWgwd, verify that equipment listed above my signature is: 1) thus actual equipment inrmlled; 2)
equtvalcm to or more ef3icicat than dua specified in the cwlific2te of complim" (Form CF-IR) subatitted for compliance
whit the EneW ,F.,} Wemy Stand►mrds fbr residential buildings; and 3) equipment that meets or exceeds the appropriate
regoiternarts for manufactured devices (Ruts dmAlpplfonee EffkkrrcyRrgrrLatf w or Pat 4 where applkaWe.
Installing Sibcorttrac.-ror (Co. Neale) OR Gum -A s.
Contractor (Co. Name) OR Owner
Cepiet t6a 191WING DEPARTWFAT, HERS RATER (IF APPLTCABL ) ]PUR )t1YG OWNER AT OCCMANCX
1te81dendad Compl once Furrw Seplephbe-r 1005
INSTALLATION CERTIFICATE
(Page 2 of 12) CF-6R
Site Address
Permit Number
An installation certificate is required to be posted at the building site or made available for all appropriate inspections. (The
information provided on this form is required) After completion of final inspection, a copy must be provided to the building
department (upon request) and the building owner at occupancy, per Section 10-103(a).
FENESTRATION/GLAZING:
Product SHGC 2
(�CF-Mvalue)
1
QuantityT-otal --
Like Product
(0 nal)
--- --
Square
Feet
- -1
,
Shading Device
or Overhang
Comments/Lor-ation/
Special Features
®
I-..
L 1.r
Use values from a fenestration product's NFRC label. For fenestration products without an NFRC label, use the default
values from Section 116 of the Energy Efficiency Standards.
2) Installed U-factor-must be less than or equal to values from CF-1R. Installed SHGC must be less than or equal to values
from CF-1R, or a shading device (exterior or overhang) is installed as specified on the CF-1R. Alternatively, installed
Weighted average U-factors for the total fenestration area are less than or equal to values from CF-1R. If using default table
SHGC v ues from § 116 identify whether tinted or not.
✓ I, the undersigned, verify that the fenestration/glazing listed above my signature: 1) is the actual fenestration
product installed; 2) is equivalent to or has a lower U-factor and lower SHGC than that specified in the certificate of
compliance (Form CF-1R) submitted for compliance with the Energy Efficiency Standards for residential buildings; and
3) the product meets or exceeds the appropriate requirements for manufactured devices (from Part 6), where applicable.
I
Item #s
(if applicable)
Si a e Date
�Q ���
Installing Subcontractor (Co. Name) OR
General Contractor (Co. Name) OR Owner
OR Window Distributor
Item #s
Signature Date
Installing Subcontractor (Co. Name) OR
(if applicable)
General Contractor (Co. Name) OR Owner
OR Window Distributor
Item #s
Signature Date
Installing Subcontractor (Co. Name) OR
(if applicable)
General Contractor (Co. Name) OR Owner
OR Window Distributor
Copies to: Building Department, HERS Rater (if applicable) Building Owner at Occupancy
¢r
Residential Compliance Forms April 2005