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09020093 CITY OF CUPERTINO BUILDING DIVISION PERMIT sm, BUILDING ADDRESS: PERMIT NO. 11 )SE PLUMBING TT\J(' oqo9nng3 OWNER'S NAME: PERMIT ISSUE DATE 'HO : S A CONTROL NO. ARCH1'IECT/ENGiNEER: 408) 296-1820 BUILDING PERMIT INFO BLDG EO PLUMB MECH �O O LICENSED CONTRACTOR'S DECLARATION U I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description 2 m with Section 7000)of Division 3 of the Business and Professions Code,and my license is y in full force and effect WTR HTR RE PLCMNT �Z License Class Lic.N C-0 Date Contractor eZi ARCHITECTS DECLARATION j m U I understand my plans shall be used as public records a cin Licensed Professional 1. y 3 OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the 0 O following reason.(Section 703 1.5,Business and Professions Code:Any City or county y Pi which requires a permit to construct,alter•improve,demolish,or repair any structure Z y prior to its issuance,also requires the applicant for such permit to file a signed statement EO e` that he is licensed pursuant to the provisions of the Contractor's Irt•ensc Law(Chapter 9 Sq.Ft.Floor Area Valuation X t- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or y that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number not more than five hundred dollars(5500) Occupancy Type ❑I,as owner of the property,or my employees with wages as their sole compensation, 362260L2 . 00 will do the work,and the structure is not intended or offered for sale(Sec.7044,Business and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections 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 We.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 sate.). ❑L 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 does not apply to an owner of property who builds or improves thereon,and. who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. ❑I am exempt under Sm B&P C for this reason Ownery� Date 2 aOO WORKER'S COMPEIMWOlq 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 Worker's Compen- .con,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 Worker's Compensation Insurance carrier and Policy number am: Carrier. Polity No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE or Icss)(This section need not be completed if the permit is for one hundred dollars($100) 1 certify that in the performance of the work for which this permit is issued,1 shall not employ any person in any manpp as become subject to the Workers'Compensation Laws of California.Date_— ��D GGY Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Workces Compensation provisions of the Labor Code,you must ,J O forthwith comply with such provisions or this permit shall be deemed revoked. z CONSTRUCTION LENDING AGENCY I hereby affirm that there is a conswction lending agency for the performance of tx the work for which this permit is issued(Sec.3097,Civ.C.) �W Q Lender's Name ]Z Lender's Address U 0 1 certify that I have read this application and state that the above information is (y correct.I agree to comply with all city and county ordinances and state laws relating to 0 V building construction,and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. W (We)agree to save,indemnify and keep harmless the City of Cupertino against H col liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. �y 'h APPLICANT UNDERSTANDS AI WILL CO PLY WITH ALL NON-POINT Issued by: Date SOU ULA'I�ONS. / � "`� Re-roofs CT Signature of Apphcaacter HAZARate i HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Munic. al Code.Chapter 9.12,and the Health and Safety Code,Section zss32(a)?❑Yea o All roofs s.iall be inspected prior to any roofing material being installed. Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove lit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. strict? ❑Yes C51N. 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the building docs not currently have a tenant.that h is my responsibility to notify the occupant of the requirements which m t be met prior ssuance of crtiftcate of Occupancy. Signature of Applicant Date or better Owner or authonzcd agent -( tc All roof coverings to be Class'A �C)A oc'93 CITY OF CUPERTINO WATER HEATER CUPEkTINO PERMIT APPLICATION FORM APN # �, l_ Date: Building Address: i ! Ct VAv>^>^y14F-kq Owner's Name: Phone #: *Z-AtAZf-rVAN X1{0&) 3411 -11t1g1 Contractor: Phone #: 4,aj 3q -- 2S1 2- Fax #: Cupertino Business License #: Contractor State License #: Contact: Phone #: Fax #: Building Permit Info: Bldg ❑ Elect Plumb -- Mech E�- Residential 0,-- Commercial ❑ Job Description: 1�lpt��72 NrE�``f(Z K£PL-ACf-*A0JT Strapped On Platform Bondec. ❑ New Location ❑ Replacement Valuation (cost of project): .,o,o Project Size: ExpressEZ Standard 0 Large ❑ Major ❑ Green Building: Please complete relevant pc rtion of the Green Building Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Green Building Points achieved: Revised 01/07/09 CITY OF CUPERTINO Kt '` WATER HEATER CUPEkT1NO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Permit Type Group 1PC1WHEATR Commercial "Nater B PCWHEATR HeaterNent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICOM Seismic Commercial B 1PRWHEATR Residential Mater B PRWHEATR HeaterNent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1 BSEISMICRE Seismic Residential B 1 PPERMITFEE Plumbing Permit P C 1 TRAVDOC Travel & B Documentation 1 BUSLIC Business Licimse B M.Indoor Air Quality and Finishes 1.Use Low/No-VOC Paint 1 IAQ/Health pts y=yes 0 2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0 3.Use Low/No VOC Adhesives 3 IAQMealth 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 6IAQ/Health pts y=yes 0 6.Use Exterior Grade Plywood for Interior Uses 1 IAQMealth pts yeses 0 7.Saul allE posed?aAbbboaid or MDF 4 IAQ/Health pts y=yes p S.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes D 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 7D 1 i i N.Flooring 1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0 2.Use Rapidly Renewable: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 p S.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0 I i i i Total Points Available: 140 13-0E---5-71 Total Points Project Received: - L 01 01 0 G:data/progs/ireenbuildingguidelines/ramodelers/greenpointsfina1212.Mproteatedxls Community Development 10300 Torre Avenue 4. �; Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 ',UPEkTINO Buildi.n De artment JOB ADDRESS: PERMIT # j 101 �}oLuy H�A� 1_N- OWNER'S NAME: q�yl aaAPJ S_ PHONE k4s 394-419L-- GENERAL q 19GENERAL CONTRACTOR: 50rtj 0SF 19L\jv 01r4t- FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and corn plete the following ' ormation: SUBCONTRACTOR BUSDVESS 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 OwnerA;oRtrfc-[or Signature Date