09100054I , CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 10171 VICKSBURG DR I CONTRACTOR: AHMED SALLAM PERMIT NO: 09100054
OWNER'S NAME: AHMED SALLAM
ER'S PHONE: 4086446338
11
License Class
Contractor
LICENSED CONTRACTOR'S DECLARATION
Lic
Date
I 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:
1 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
performance of the work for which this permit is issued.
I 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
permit is issued.
APPLICANT CERTIFICATION
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,
costs, and expenses which may accrue against said City in consequence of the
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.
Date
ISI'\ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the stricture 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
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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
performance of the work for which this permit is issued.
I 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
permit is issued.
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, 1
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
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
i nify and keep harmless the City of Cupertino against liabilities, judgments,
c. , and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source egulations er the Cupertino Municipal Code, Section
9.18.
Signa Date O 7
9
10171 VICKSBURG DR
CUPERTINO, CA 95014
DATE ISSUED: 10/07/2009
PHONE NO:
BUILDING PERMIT INFO: BLDG F_ ELECT f— PLUMB I—
MECH f— RESIDENTIAL F_ COMMERCIAL r—
JOB DESCRIPTION: INSTALLING 3 TO 4 SUN TUNNELS. ALL
TOGETHER UNDER
10 SQ FT. DOING SO WHILE DOING RE -ROOFING
Sq. Ft Floor Area: I Valuation: $1000
APN Number: 36907006.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued Date
RE -ROOFS:
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 "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should 1 store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner authorized a ent:
A / i i /� . Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
3 ITEMS OF 3
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 36907006.00
DATE ISSUED.......: 10/07/2009
RECEIPT #......... BS000008860
REFERENCE ID # ...: 09100054
SITE ADDRESS .....: 10171 VICKSBURG DR
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......
OWNER AHMED SALLAM
ADDRESS ..........: 10171 VICKSBURG DR
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
RECEIVED FROM ....: AHMED S SALLAM
CONTRACTOR .......: LIC # *OWNER*
COMPANY AHMED SALLAM
ADDRESS 10171 VICKSBURG DR
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
TELEPHONE .........
OPERATOR: patg
COPY # : 1
FEE ID UNIT
QUANTITY
AMOUNT
PD -TO -DT
THIS REC
NEW BAL
----------
-----------------------
1BCBSC VALUATION
----------
1,000.00
----------
1.00
----------
0.00
----------
1.00
0.00
1BSEISMICR VALUATION
1,000.00
0.50
0.00
0.50
0.00
1SKYL<10SF EACH
1.00
380.00
0.00
380.00
----------
0.00
----------
TOTAL PERMIT
----------
381.50
----------
0.00
381.50
0.00
METHOD OF PAYMENT
AMOUNT
REFERENCE
NUMBER
----------------- ---------------
CHECK
381.50
--------------------
#748
---------------
TOTAL RECEIPT
381.50
OWNER -BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent, spouse or child) will perform:
A. �All the work authorized by this permit
B. _ A portion of the work
C. None of the work
If B or C is checked, complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
L . p..rL.,.= e
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm
Address/City Phone Number I Type of work to be
I declare under penalty of perjury that the above is true and correct.
Owner -Builder Information (revers ide).
Property Owner's Signature:
Job Address: 0 71 V W USLd f4 A CW JOCY&D
—I
I have read and understand the
01,
Date: '7210109
Permit # i 0 Uc J L4
-
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
CITY Of
CUPEkTINO
CITY OF CUPERTINO
GENERAL BUILDING
PERMIT APPLICATION FORM
APN #� 5 (4--)( 7 o� (P - 6
ate: W d 7 /0-f�,
Building Address: N17/ 17/
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes No
HOA: Exterior work only) Yes ❑ No t, If yes,
provide letter from HOA
� n �CA"Phone
Owner's Name:OwnN
#:
Contractor:
PC,./ Adv- u � '
Phone: 4'0 �' � 6<4 C( ^633 �
Fax:
Contractor License #:
Cupertino Business License #:
Contact: S A L �A n �
AflM60
Phone:
Fax:
Residential a Commercial
Job Description: 1 Yvj I
p l.J
S Lt
J
& A A -SC_
Building Permit Info:
Bldg Elect ElPlumb ElMech El
Type of Construction (Usage Class):
Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV -HT, V -B
Valuation: 10 10 d 69
Square Footage:
Project Size: Express E3 ---Standard ❑ Large ❑
Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set & the sheet index.
Points Achieved:
For heli), contact Build it Green at
23
Revised 07/14/09
CITY OF
CUPEI�TINO
CITY OF CUPERTINO
GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf
Fee ID
Fee Description
Fee
Group
Permit Type
1GENRES or
1GENCOM
PARTITION WALLS
1 PARTICOMM
Partition Interior Commercial
B
1PARTICOMM
1PARTIR
Partition Interior Residential
B
1PARTIR<=30
RETAINING
WALL(CONCRETE
OR MASONRY
1RETSTN
Standard (up to 50 ft)
B
1RETSP310
Special Design, 3-10' high (up to 50 `)
B
1 RETSP 10
Special Design, over 10' high (up to
50')
B
1RETCRB<
Gravity/Crib Wall, 0-10'high (up to
50 ft)
B
1RETCRB> -
Gravity/Crib Wall over 10' high (up to
50 ft)
B
SIDING
1 SIDEST/BK
Siding, Stone & Brick Veneer
(interior/exterior)
B
1 SIDEOTHER
Siding all other
B
SKYLIGHTS
1 SKYL<10 SF
Skylight less than 10 sf
B
1 SKYL> l 0SF
Skylight greater than 10 sf or
structural
B
1STAIRS
Stairs -first flight/ea addt'l
B
STORAGE RACKS
1 SRACKS<=8
Storage Racks 0-8' high (up to 100 sf)
B
1 SRACKS>8
Storage Racks over 8' high (up to 100
st)
B
4 of 5
� ZM�
CITY OF
CUPEI�TINO
CITY OF CUPERTINO
GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf
Fee ID
Fee Description
Fee
Group
Permit Type
1GENRES or
1GENCOM
1STUCOAP
Stucco Applications (up to 400 sf)
additional stucco application
B
1 WINREP
Replacement windows/sliding glass
door (ea 8 windows)
B
1 WINMEWSTR
New Window -structural shear
wall/masonry (includes plan ck fee)
B
1 EPERMITFEE
Electrical Permit Fee
E
1MPERMITFEE
Mechanical Permit Fee
M
1 PPERMITFEE
Plumbing Permit Fee
P
1 ELCPLNCK
Stand Alone Electric Pln Ck (hourly)
E
1MECPLNCK
Stand Alone Mechanical Pln Ck (hrly)
M
1 PLMBLNCK
Stand Alone Plumbing Pln Ck (hrly)
P
1 STPLNCK-(3 Hr Min
when not over counter)
Standard Plan Check (when no E/M/P)
hourly -stand alone
B
1BCBSC
Cal Bldg Standards Commission Fee
B
ALL PERMIT
TYPES
1BSEISMICR
Seismic Residential
B
1BSEISMICO
Seismic Commercial
B
1 TRAVDOC
Travel & Documentation
B
1BUSLIC
Business License
B
5 of 5
1. Use i OWWVOC Paint
2. Use Low VOC, Water -Based Wood Finishes
3. Use LowMo VOC A vas
4. Use Salvaged Materials for Interior Finishes
5. Use Engineered Sheet Goods with no added Urea
Formaldehyde
6. Use Exterior Grade Plywood for Interior Uses
7. Seal SII &pcsW.P ldebw"_;MV
8. Use FSC Certified Materials for Interior Finish
9. Use Finger -Jointed or Recycled -Content Trim
10. Install Whole House Vacuum System
N. Flooring
1. Select FSC Certified Wood Flooring
2. Use Rapidly Renewable Flooring Materials
3. Use Recycled Content Ceramic Tiles
4. Install Natural Linoleum in Place of Vinyl
5. Use Exposed Concrete as Finished Floor
6. Install Recycled Content Carpet with Low VOCs
Total Points Available:
Total Points Project Received:
1 IAQ/Health pts
y=yes
21AQ/Health pts
y=yes
31AQ/Health pts
y=yes
3 Resource pts
y --yes
61AQ/Health pts
y=yes
1 IAQ/Health pts
y=yes
41AQ/Health. pts
y=yes
4 Resource pts
y=yes
1 Resource pts
y=yes
3 IAQ/Health pts
y=yes
6 Resource pts
y=yes
4 Resource pts
y=yes
4 Resource pts
y=yes
5 IAQ/Health pts
y=yes
4 Resource pts
y=yes
4 Resource pts
y=yes
ld/ d
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