10070117 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 6370 BLACKWOOD DR CONT 2ACTOR•ILD Tn uF n> r vn
F�,rrn;E-D PERMIT NO: 10070117
OWNER'S NAME: JOE QIU -,,Q DATE ISSUED:07/16/2010
4ER'S PHONE: 4086566570 '+'` HONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# ( 4
_ �-{� MECH RESIDENTIAL COMMERCIAL
Contractor `V�� l lDate i ,c
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL 14 FLUORESCNT RECESSED LIGHTS IN LIVING
(commencing with Section 7000)of Division 3 of the Business&Professions ROOM`.&3 BEDROOMS
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two 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 Sq.Ft Floor Area: Valuation:$1800
permit is issued.
APPLICANT CERTIFICATION APN N ember:36917050.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
- Signature IG�ti'L Date Issued bye Dater
L� OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspecti)n.
will do the work,and the stricture is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signatu•e of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have i ead the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. Califor iia Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by complis.nce with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health &Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must Owne er aulborized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. r r ` ' Date: I V
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender s Name
upon the above mentioned property for inspection purposes.(We)agree to save
—ify and keep harmless the City of Cupertino against liabilities,judgments, Lender s Address
ind expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. I unders:and my plans shall be used as public records.
Signature Date Licensed Professional
CITY OF CUF'ERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 7
DATE: REVIEWED BY:
APN: BP#: *VALUATION: 1$1,800
`PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex APPLICATION
USE: j TYPE:
� a
3c
APPLIANCE/EQUIP TYPE CAPACITY FEE ID QTY BP FEES
Fixtures, Lighting 1BREMFIXI 14 $63
TOTALS: $63.00
Elec.Plan Check 0.0 hrs $0.00
Elec.Permit Fee: IEPERMIT
FT-� -17
;. Other Elec.Insp. 0.0 1 hrs 1 $42.00
NOTE. Thesefees are based on the preliminary information availab,'e and are only an estimate. Contact the De t or addn'1 info,
FEE ITEMS (F'ee Resolution 09-051 FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $63.00
PME Permit Fee: $42.00
Travel Documentation Fee: ITRA VDOC $42.00
_' Select an Administrative Item
Bld-- Stds Commission Fee: IBCBSC $1.00
SUBTOTALS; $148.001 $0.00 TOTAL FEE: 1 $148.00
Revised: 6/30/2010
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lost:
APN . . . . . . . . : 369170"0 . 00
DATE ISSUED. . . . . . . : 07/16/2010
RECEIPT #. . . . . . . . . : BS0000:.0885
REFERENCE ID # . . . : 100701:.7
SITE ADDRESS . . . . . : 6370 BI,ACKWOOD DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERT::NO
IMPACT AREA . . . . . . :
OWNER . . . . . . . . . . . . . JOE QIIJ
ADDRESS . . . . . . . . . . : 6370 BI,ACKWOOD DR
CITY/STATE/ZIP . . . : CUPERT::NO, CA 95014
RECEIVED FROM . . . . : TONY TRAM CONSTRUCT
CONTRACTOR . . . . . . . : TBD — "0 BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD — "0 BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUTJT PD—TO—DT THIS REC NEW BAL
---------- ------------- ---------- ------ ---- ---------- ---------- ----------
1BCBSC VALUATION 1, 800 . 00 1 . 00 0 . 00 1. 00 0 . 00
1BREMFIXT NO. FIXTURES 14 . 00 63 . 00 0. 00 63 . 00 0 . 00
1EPERMITFE FLAT RATE 1 . 00 e:2 .00 0. 00 42 . 00 0 . 00
1TRAVDOC FLAT RATE 1 . 00 x:2 .00 0 . 00 42 . 00 0 . 00
------ ---- ---------- ---------- ----------
TOTAL PERMIT 12:8 .00 0 .00 148 . 00 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --- -----------------
CHECK 148 . 00 #692
---------------
TOTAL RECEIPT 148 . 00
CITY OF CUP ERTINO
CITY OF
CUPE�T1NO GENERAL BUILDING
PERMIT APPLIC2�TION FORM
APN# Date:
Building Address: Co
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes 0 No
HOA: (Exterior work only) Yes ❑ No ❑ If yes,provide letter from HOA
Owner's Name: Phone#:
5�� l �
Contractor: -- Phone: (t''
Fax: -24-
Contractor
-Contractor License#: L (�
Cupertino Business License#:
Contact: _ Phone: L�o;n5 Jr,)- 414
Residential Commercial
Job Description: f �l k &ik L -�L U°C,44 1 S I k
Building Permit Info:
Bldg ❑ ElectQ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ I EI B, IV-HT, V-B
Valuation: Square Footage:
Project Size: Ex ress D"Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Bu' ding/LEED Checklist& attach it
to the application or if applicable, include in plan set& the sheet index.
Points Achieved:
I For help, contact Build it Green at www.buildityreen.or T
Revised 07/14/09
M.Indoor Air Quality and Finishes
1.1sla -'O FWN 1 IADAiealth pts y--yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAWiealth pts y=yes 0
3.Ljsa LlDvft VOC Adhagm3 IAQ/Iiealth pts y=yes p
4.Use Salvaged Materials for Interior Finishes 3 Rescurce pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQA iealth pts y=yes 0
p
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/liealth pts y--yes
7�i I �_ . ---.. 41AQ/tiealth. pts y--yes 0
8.Use FSC Certified Materials for Interior Finish 4 Rescurce pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Rescurce pts y=yes 0
1 1
10.Install Whole House Vacuum System 3 IAQ/dealth pts y--yes 0
1 i 1
N.Flooring
1.Select FSC Certified Wood Flooring 8 Resou-ce pts y=yes 0
2
Use Rapidly Flanewable Fborwq Matanals 4 Resou-ce pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resou-ce pts y--yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/H aalth pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resou-ce pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resou-ce pts y=yes 0
1 1 1
Total Points Available: I 140t 1301 57
Total Points Project Received:1 1 01 01 0
G:data/progs/greenbuildinggt idelinWremodelerslgreenpointsfina1212 Mprotected.xls
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: %��V ,-UIUT Dr< PERMIT# Q
OWNER'S NAME: U PHONE
GENERAL CONTRACTOR: BUSINESS LICENSE#
ADDRESS: C I ck-(j�- — 3 �,3] CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
ignature 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
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date