10100151CITY OF CUPERTINO BUILDING PERMIT
I BUILDING ADDRESS: 1515 POPPY WAY I C ONTRACTOR:' 1117),—`P6�BE I PERMIT NO: 10100151
FTER11 40i9Q
' e: ifrz�flsr
OWNER'S NAME: SCOTT NELSON
JVNER'S PHONE: 4089168067
U-1 LICENSED CONTRACTOR'S DECLARATION
License Class /-7-7336
/�3 3 G _( Lic. # 67
Contractor C1 G/J 6 e-
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:
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
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.
Signature, Date
❑ 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 structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
I, 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.
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 Worker's
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
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
-in the above mentioned property for inspection purposes. (We) agree to save
unify and keep harmless the City of Cupertino against liabilities, judgments,
...,,its, 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.
Signature Date
DATE ISSUED: 10/20/2010
PHONE NO:
J JB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL
ILEPLACE SHOWER PAN, NO FIXTURES OR TRAP
CHANGE
REPLACE DRYWALL AND TILE AT SHOWER
Sol. Ft Floor Area:
Valuation: $200
I A PN Number: 36615028.00 I Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DA R0MM LASS' CALLED INS/PEC ION.
_7f Is iued by: Date: (`� a
RE -ROOFS:
Al I roofs shall be inspected prior to any roofing material being installed. If a roof is
in: tailed without first obtaining an inspection, I agree to remove all new materials for
in: pection.
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
Ca lifornia Health & Safety Code, Sections 25505, 25533, and 25534. I will
mi intain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
mi terial. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
wil I maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and 25534.
Ov,ner or authorized agent: Date:,6 Zezzo
CONSTRUCTION LENDING AGENCY
I h4 reby affirm that there is a construction lending agency for the performance of
wo Vs for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Leiider's
ARCHITECT'S DECLARATION
I ur derstand my plans shall be used as public records.
Lic.nsed Professional
CITY OF CUEERTINO
3 ITEMS OF 3 PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 36615C28.00
DATE ISSUED.......: 10/20/2010
RECEIPT #.........: BSOOOC11796
REFERENCE ID # ••.: 10100151
SITE ADDRESS .....: 1515 FOPPY WAY
SUBDIVISION ......
CITY .............. CUPERgINO
IMPACT AREA ......
OWNER ............: SCOTT NELSON
ADDRESS ..........: 1515 SOPPY WAY
CITY/STATE/ZIP ...: CUPERgINO, CA 95014
OPERATOR: SylviaM
COPY # : 1
RECEIVED FROM ....: KENNEZH DEVELOPMENT
CONTRACTOR .......: TBD - TO BE DETERMINED LIC # 00096
COMPANY ..........: TBD - TO BE DETERMINED
ADDRESS ..........
CITY/STATE/ZIP ...: ,
TELEPHONE ........
FEE ID UNIT
QUANTITY
AMOLNT PD
-TO -DT
THIS REC
NEW BAL
-----------------------
1BCBSC VALUATION
----------
200.00
--------------------
1.00
0.00
----------
1.00
----------
0.00
1BSEISMICR VALUATION
200.00
0.50
0.00
0.50
0.00
1SUPINSFEE HOURS
2.00
252.00
0.00
252.00
0.00
TOTAL PERMIT
---------- ----------
253.50
0.00
----------
253.50
----------
0.00
METHOD OF PAYMENT
AMOUNT
REFERENCE
NUMBER
----------------- ---------------
CHECK
253.50
--------------------
12 155
---------------
TOTAL RECEIPT
253.50
1. Use Low/No-VOC Paint
2. Use Low VOC, Water -Based Wood Finishes
3. Use LowlNo VOC Adhesives
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 aU EVosed ftrtiolebaard or MDF
B. 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 13enewable f=looring 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 IA(lHealth pts
y=yes
21AOjHealth pts
y --yes
3 IA(lHealth pts
y=yes
3 Res )urce pts
y --yes
6 IAQ Health pts
Y --yes
1 IAQ, Health pts
y --yes
4 IAQ. Health. pts
y=yes
4 Res )urce pts
y=yes
1 Res :)urce pts
y=yes
3 IAC /Health pts
y=yes
B Rescurce pts
y=yes
4 Resc urce pts
y=yes
4 Resc urce pts
y --yes
5 IAQIHealth pts
y=yes
4 Resc urce pts
y=yes
4 Resc urce pts
y=yes
1401 730 57
51 0 0
lGI/L6/1/o
G:date/progs/greenbuilrfin 39uidelinWremodelers/greenpointsfinal212.04protected.)ds
CUPERTINO
CONTRACTOR/ SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS: 5-1S-0P/� Cy 4J;4 CU PERMIT #
OWNER'S NAME: 5 -Cc' T PHONE # `7 6
GENERAL CONTRACTOR:BUSINESS LICENSE #
ADDRESS: 0 9 o '� q% 4041- CITY/ZIPCODE: S 7� Z -
*Our municipal code requires all businesses working in the --ity to have a city or c:upernno Dusiness ncense.
NO BUILDING FINAL OR FINAL OCCUPANCY INS1'ECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. y
1 am not using an subcontractors:
Y
Signature Date
Please check applicable subcontractors and complete t he following information:
6/
SUBCONTRACTOR
BUSINESS 1` AME
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
gheet Rock
e
Owner / Contractor Signature
Date
1-1— S-Uz�o
CITY OF
CUPEKT1NO
APN # lX/ r
Building Address:
CITY OF CUPJ�RTINO
GENERAL BUILDING
PERMIT APPLICATION FORM
e
Date: 1,0,116
Mailing Address (if different from building as �3)l'a�`
Are Hazardous Niaterials being used as part of this project? Yes
HOA: (Exterior work
Yes U No
Owner's Name:
Lz,
Contractor: g * -,- l -> m z -a f
Contractor License #: --7 -71.5 3 6 l
cz
No�i
If yes, pi ovide letter from HOA
Phone #:l - �d ._ 7/1 -7
Phone:
Fax:
Cupertino Business License #:
Contact: b h� 5.3,,J /Y�! `Le
Phone: cl - Z 7� '�� 4t'�
�G� Gu hJ Fax: , c s _� . /s2 �C
_.esidential Commercial
Job Description: �jyi✓/�GL 1) e- L,) /
Building Permit Info:
11 Elect ❑
Type of Construction usage tiasb).
1-A, 1-B L1 U/IMV-A
Valuation .Z v a—
Project Size:
Plum ) ❑ Mech ❑
Occupancy Type:
1= B, IV -HT, V -B i s=
Square Footage:
tandard
or
Green Building: Please complete relevant portion of the Greeding/LEED Checklist & attach it
to the application or if applicable, include in plan set & the sheet index
Ants Achieved:
or help, contact Build it Green at www.builditgreen.o -
Revised 07/14/09