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09030006 CITY OF CUPERTINO T �y BUILDING DIVISION PERMIT L� l4�Ms4 � r BUILDING ADDRESS: PERMIT NO. 22013 BAXLEY CT ALBERT WAISSMAN 09030006 PERMIT ISSUE DATE NER'S NAME: A O. 9 9 9 CONTROL NO. PHONE: BUILDING PERMIT INFO ARCHIECTIENGINEER: BLDG ELECT PLUMB MECH u p p LICENSED CONTRACTOR'S DECLARATION Job Description m I hereby affirm that I am licensed under provisions of Chapter 9(commencing Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is RMV POOL L 10 0 S Q n�yin full fora and effect License Claw Lie•g n F,0 Date Contractor ARCHITECTS DECLARATION I understand my plans shall be used as public records �yU 4 O y Licensed Professional N W OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractors License Law for the p O following mason.(Section 7031.5,Business and Professions Code:Any city or county m P which requires a permit to construct,alter,improve,demolish,or repair any structure prior to its issuance.also requires the applicant for such permit to file a signed statement Valuation that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Y.t-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $100 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 Occupancy Type not more than five hundred dollars(5500). 35606021 . 00 0 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 Required Inspections and Professions Code:The Contractor's 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 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.). 0 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 Caw 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. B&P for this mason I am exem under Sec.0 mer. ' A�L/�/��iSr�a Date ' ---WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: 0 I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- sation,as provided for by Section 3700 of the Labor Code.for the performance of the work for which this permit is issued. 0 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 Workees Compensation Insurance carrier and Policy number are: Career: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any mannc so as to become subject to the Workers'Compensation Laws of California Applicant NOTICE TO APP ANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must ,J 0 forthwith comply with such provisions or this permit shall be deemed revoked. Z""' CONSTRUCTION LENDING AGENCY [~t I hereby affirm that there is a construction lending agency for the performance of a the work for which this permit is issued(Sec.3097.Civ.C.) a A Lender's Name Gender's Address U 0 1 certify that I have read this application and state that the above information is LL" 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 Uabove-mentioned property for inspection purposes in. (We)agree to save,indemnify and keep harmless the City of Cupertino against tE�, , A" t� liabilities,judgments,costs and expenses which may in any way accntc against said City U Z in consequence of the granting of this permit. Date ►+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued Ey: SOU RCEREGULr�I,0 S. f /oj� �`O� — /iyI Re-roof; Signature of App'litaH Contractor D're T of Roof HAZARDOUS MATERIALS DISCLOSURE Type Will the applicant or future building occupant store or handle hazardous material defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety de.Section 25532(a)? All roots shall be inspected prior to any roofing material being installed. 0 Yes XNo If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? 0 Yes 1?110 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building does not currently have a tenant.that it is my responsibility to notify the occupant of the re4wnor('authori7,cd uirements which must be met prior to issuance of a Certificate of Occupancy. Signature of Applicant Date _r'C,•// � All roof coverings to be Class'"or better agent Date Ogp (P am CITY OF CUPERTINO DEMO CUPE(�TINO PERMIT APPLICATION FORM APN# Date: 3. Building Address: r DD ej c Mailing Address (if different from building ad b-ess: �l Ly Owner's Name: Phone: Contractor: Phone Fax: Contractor License #: Cupertino Business License #: Contact: Phone: Fax: Residential Sq Footage 5V Commercial ❑ Sq Footage Job Description: 0C Valuation: Project Size: Express �tandard ❑ Large EJMajor ❑ Please complete relevant portions of the Green Building Checklist & attach it to the application or if applicable, include on the plan set & the sheet index. Quantity Fee ID Fee Description Fee Group Permit Type 1DEMORES Demo-Residential B 1SFDWL-DEM I 1 DEMOPRES Pool Demo Residential B 1SFPOOL-DEM 1 1BCBSC Cal Blc.g Standards B ALL PERMIT Commi 3sion Fee TYPES 1BSEISMICRE Seismic Residential B Revised 01/07/09 ENTER PROJECT NAME mill gEnter description h-ere--and-enter-points"available-for measure In-ap,propqiate categories to the 0 1111. 0 0 0 0 �D Enter desripton here,and enter points available for measure In appropriate categories to the 6 1hL 0 0 0 0 0 0 Enter description hem,and enter points available for measure In appropriate categories to the 0 1hL 0 0 0 0 0 _JR Enter description hem,and enter points available for measure In appropriate categories to the ii IhL 0 0 0 0 0 0 Flueld It Green Checklist,and 4.Innovation:List innovative measures that meet the green building objectives of the Guidelines.Enter up to a Guidelines maximum combined total of 20 pts.See Innovation Checklist for suggested measures,using the link to the right. Innovation in community:Enter description here,and enter points available for measure in app opriste categories to the right 0 0 0 0 0 0 Innovation In Energy:Enter description hem,and enter points available 11or measure In appropri its categories to the right 0 0 0 0 0 0 Innovation In LAQ%alth:Enter description hem,and enter points available tot measure In app opriste categories to the NhL 0 0 0 0 0 0 Innovation in Resources:Enter description hem,and enter points available for measure In appopriate categories to the right. 0 0 0 0 0 0 Innovation in Water Enter description hem,and enter points available for measure In epproprii to categories to the right D 0 a 0 0 Total Available Points In Other=4 0 Summary Total Available Points in Specific Categories* 4+ 96+ 42+ 66+ 43+ Ninimum Points Required in Specific Categories oPoed 01 Ttal ints Achiev0 0 0 0 A 1Projecthas not yet met the following recommended minimum requirements: Total Project Score of At Least 50 Points Required measures: -A3a:50% waste diversion by weight -12: 15%above Title 24 -N1:Incorporate Green Point Rated Checklist into blueprints Minimum points in specific categories: -Energy(30 points) -IAQIHealth(5 points) -Resources(6 points) -Water(9 points) 0 2007 Build It Green Single Family GreenPoint Cheddist 2007 Version Page 7 of 7 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CIV OF Fax(408)777-3333 CUPEkTINO Building Department JOB ADDRESS: PERMIT # O O O 220/3 pP c C� e C 5 l O� OWNER'S NAME: PHONE # GENERAL CONTRACTOR: FAX # I am not using any subcontractors: ��---- 3 �j 5 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 Owner/Contractor Signature Date