09010004 CITY OF CUPERTINO
BUILDING DIVISIONERTI PERMIT +C 11`+TRAC CT Z�U MATI�1
• PERMIT NO.
BUILDING ADDRESS:
6101 B-)T,T,TNGER T PERMrr ISSUE DATE
OWNER'S NAME:
A O. 6 8 9 CONTROL NO.
)W4, 326 PHEE3
408) 230-5569
BUILDING PERMITINFO
ARCHrfECTIENGINEER: BLDG ELECT PLUMB MECH
Z p p LICENSED CONTRACTOR'S DECLARATION Job Description
mC Professions hereby affirm that I am licensed under provisions of Chapter 9(commencing
zUwith Soction 7000)of Division 3 of the Business and profeasioCode.and my license is
ro RE PLC SEWER LATERAL
a in full force and effect
j
Z)CA License Class Lam•
a Date Contractor Q\ —
L".m ARCHITECTS DECLARATION
gg.�
pr,< I senders nd my plans shall he used as public records
�yU
1.o y Licensed Prufessional
OWNER-BUILDER DECLARATION
2 1 hereby affirm that I am exempt from the Contractors License Law for the
cc following reason.(Section 7031.5,Business and Professions Code:Any city or county
e m Qi which requires a permit to construct.alter,improve,demolish,or repair any structure
y"H prior o its issuance,also rcyuirea the applicant for such permit to file a signed statement Sq Ft.Floor Area Valuation
Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
Yt�� (commencing with Section 7000)of Division 3 of the Business and Professions Code)or55200
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars($500)• 37538008 . 00
❑I,ss owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure isnot intended oroffered for sale(Sec.7044,Business Required Inspections
and Professions Cade:The Contractor's License Law docs 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 intended 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 not build or improve for purpose of
sale.).
❑1,as owner of the property.am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-cense Law docs not apply o an owner of properly who builds or improves o thereon,andrr� "�AN1TARY
who contracts for such projects with a contractor(s)licensed pursuant the Contractors
License Law.
❑I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have 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 Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Ins ce carrier and Policy number are:
mjt y'by'.,cora• "w,•rout'kPolcyNo.:DtnkQY'?/—ZCb3-3)3
Ca CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for enc hundred dollars(S 100)
or Icss.)
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 workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Code,you must
,J z forthwith comply with such provisions or this permit shall be deemed revoked.
Z 0 CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
IYh> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lendces Name
a.
Z
Lenders Address
U 0 1 certify that I have read this application and state that the above information is
LL, H correct.l agree to.comply with all city and county ordinances and state laws relating o
O U building conswcn,and hereby authorise representatives of this city to enter upon the
above-mcntion property for inspection purposes
�W.h (We)a to save,indemnify and keep harmless the City of Cupertino against
Iia'ities,'ud ntscosts and expenses which may in any way accrue against said City
U z in o c bC granting of this permit. Date % V
0� ARPL A E STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SO NS.
9 Re-roofs
i '/ContractorDare T of Roof
RDOUS MATERIALS DISCLOSURE Type
app cant or future building occupant store or handle hazardous material
by pertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25 2(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ;d_". If a roof is installed without first obtaining an inspection,I agree to remove
W'11 the applicant o¢future building occupant use equipment or devices which
it ha.ius air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
"Strict?
!ha ad'the ^rdo materials requirements under Chapter 6.95 of the Califor-
nia Health�c, ty Sco:Wns 25505,25533 and 25534.1 understand dhat if the building
does noir h a tenant.that it is my responsibility to notify the occupant of the Date
require w be met prior o issu o Certificate of Occupancy. Signature of Applicant
All roof coverings to be Class"nor better
Own r or au xe Date
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 37538008 . 00
DATE ISSUED. . . . . . . : 01/05/2009
RECEIPT # . . . . . . . . . : BS000006895
REFERENCE ID # 09010004
SITE ADDRESS . . . . . : 6101 BOLLINGER RD
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : AUNG 00
ADDRESS . . . . . . . . . . : 6101 BOLLINGER RD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM " : JUAN G
UILAR
: DUARTETADEV LIC # 22189
CONTRACTOR . . . . . . .
COMPANY . . . . . . . . . . : ALLSTAR PLUMBING
ADDRESS . . . . . . . . . . : 326 PHELAN AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95122
TELEPHONE . . . . . . . . : (408) 230-5569
PD-TO-DT THIS REC ---QUANTITY
---------- ----------
----------
0 . 0
1BSEISMICR VALUATION 5, 200 . 00 0 . 60 0 . 00 40. 79 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 .79 0 . 00
1PRSEWER UNITS 1 . 00 20 . 40 0 . 00 20 .40 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 .79 0 . 00 40 .79 -----0_00
TOTAL PERMIT
102 . 58 0 . 00 102 . 58 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
--------------------
------------
---------------
CREDIT CARD 102 . 58 VISA
---------------
TOTAL RECEIPT 102 . 58
VOICE ID
DESCRIPTION VOICE ID DESCRIPTION
---------
--------- ---------
_ ----------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING
400 SEWER/LATERAL
507 FINAL PLUMBING
001 ��
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUP
CITY OF PERMIT APPLICATION FORM
APN# Date:
Building Address:
(14Owner's Name: Phone#:
Contractor. Phone#:
Fax #:
Contact: Phone#: Vo r 6-,i '7Q��-
Fax#:
Contractor License#: 73 '2 L, r
Cupertino Business License #: ZZJ
Job Description: /
Residential Commercial ❑
Valuation: �x j
Project Size: Express ❑ Standard Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set& the sheet index.
Green Building Points:
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
1BPREPIPE Commercial re-pipe per fixture P 1CPRP
1PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BSEISMICOM Seismic Commercial P
1BSEISMICR Seismic Residential P
1PRSEWER Residential building P 1RPSS
sewer/sanitary sewer
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
T�tvO FEE SCHEDULE
CuPE�
Fee Description Fee Permit Type
Quantity Fee ID p Grou
1pRREPIPE Residential re-pipe per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1PCESS Cesspool P
1BPWATER
Install/alter Water Pipe P
1BPFIXTURE Plumbing Fixture P
1PGASRES Residential Gas Piping System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
1PPERMITFEE Plumbing Permit Fee Issuance
P
1PLMBLNCK Plumbing Plan Check
P _
1PLMBINSP
Other Plumbing/gas Insp. P
1TRAVDOC Travel &Documentation Fee B
c
1BUSLIC Business License B
Revised 6-16-08
Indoor Air Quality and Finishes
1.use I -VOC Paw 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes. 0
3.Use Lowft VX Adf,esives 3 IAQ/Health pts y=yes
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 6IAQ/Health pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7,Seal as fMMW Parbd�or MDF 4 IAQ/Health pts y=yes 01
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 I I k77d
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0
2.Use Rapidly flenewable Flooring Materials 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
1 1 1
Total Points Available: 140 1301 57
Total Points Project Received:
� 01 0 0
�S I
G:data/progs/greenbuildingguidelines/remodelers/greenpointsfinal2.12.04protected.xls
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
OW OF Fax(408)777-3333
rUPEkTINO
Buildin De artment
OB ADDRESS: PERMIT #
cq
J nnoi� y
LCf
OWNER'S NAME: PHONE # - a
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: S
i tore ate
Please check applicable subcontractors and co ete 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
n •s{
J Q
Owner �a'�?ac� Signature ate