08040200 CITY OF CEj'ERTINO atmxt�a=�,y:!r��y� i3^».a�fYrmC��T+'�*- nw` T-/��y^
BUILDING DIVISION PERMIT uQa`V.1\t^1.C�1:/1� 1Y� ,Q�fr+Ai�!L,
BUILDING ADDRESS: PERMIT NO.
10240 MIRA VISTA AVE CAL—PRO ROOFING 08040200
OWNER'S NAME: PERMIT ISSUE DATE
OLSEN MELVIN N AND KRISTINE A 2914 UNION AVE 04/28/2008
E:
(408) 460-1976 SANITARY NO. CONTROL NO.
ARCH=/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
30G LICENSED CONTRACTOR'S DECLARATION lb Description
FF I botchy air,.Must w 1 licensed miner pmvisans of Chapter 9 incarcerating aSCrIP
ing
z� with Station 7000)ofDlridon 3 ofthe Basinw and Proliakru Code,and my licensee T/0 SHK&RPLC W/30LB FLT 1/2 OSB CLS A 50YR PRES
^o In full mratio and eff ��?O 1 _-
0 Llcts)Cl " Lk.g 20SQ
Date L—
9I ARCHITECTS OECI.TRA ON
1 undcntsm my pans shall E TS u public ATION
yC WccnaJ Professional -
g3 OWNER-aumpt R DECLARATION
5 1 ream einem on I em esempt from the Conlr m Co License Law for Mae
00 thawing moon Permit
t 703 IJ.Business and vis,desi0u Calc:My city or warty
$ pwhichrori requires a e,also re ennsuuct Ater,W(cove,demolish,ri repair any urumure
ZS^ pdakiuimumc4ata requires lhovisios of(coMcCchperminONose Lawdsutemenl
< that mencinnwisPuraml7010)ofDidouofth.Canusotr'WceoafaonsCoam9 Sq.Ft.Floor Area Valuation
dans M Iloln�wish Section7010)Led M bad,f r of the al eg einexe and Pourcention.My
Code)of $7000
$ Ihu M ts uempl thue(som and dte huts fa We alleged exemption.MY Notation of
Sce don 70343 by any applicant for a permit subjects the applicant Ina civil penalty ofNumber Occupancy Type
sot more thm five hundred&It=($M 3 570202 8 .Vy
1,uownerofinspmpmmy,mmyemplawuwithwg utheirsokc=M mdea,
awe Ppsurreead�`c�The Con actalrsu�Law,mensnWe�ly�'�� Required Inspections
P"WertYvM Wilds or improves themn,end whodoessuch went Manselfmthrough his
owe=play=.proNded that each improvements are net intended aoRered fresh B.
however.the Wilding or ImProvenmat is mid within am year of ecmpkdon.We owmr-
belldm will have da Wide.of paving that M did no,Wild a improve for purpose of
0 1.u^uer of rM propmy,am esclusively co anti ng with reacted contractors In
mutrum the pro)mt(Sec 1041.Bust.and Ptofrsdons Code)This Contsoters u.
roue law does not apply m an owner of properly who Wilds or imp ower thereon,red.
who contracts for such prefects with a conuamor(s)lieenad pmuant to 1M Contractors
Linen law.
0l sso uempl under Sm .B l P C far Mos recon
Omar Due
WORKER'S COMPENSATION DECLARATION
I hereby aBSrre under penalty of p jury am of the following declandoi¢
1 haw and will maintain a Cenifuau of Co..,in alf-insue for wortere Campos-
ad.".u provided fa by Semtan 3700 of don labor Code,far use pedafmafrce of the
work for which We permit is iauN.
❑1 hove ad will maintain Workers Compensation Inaunnce,as acquired by Seeks
3700 of the later Code.far the performance of die went for
1which this permit h issued.
My WCasr 2-MAP 'T'UAlT No.:—Ji 1 o3 / Cf
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Ihtallon nerd at Im completed Italian permit is forme hundred dollar($100)
or leu)
1 certify, dent in Mos Performance of the wast for which this pant Is issued,l OWI ml .
employany person in say mmnerse is In become subject to the Women'CMpcw W
Laws of Caliromis.Data
Applicmt
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you shout
Went,a subject m Man Wolters Compensation provisiats of Mae later cmc,you mass
0 O ImnWith comply with much Provisions or this permit Nall be dmmm tcwkm.
y CONSTRUCTION LENDING AGENCY
[-r 1Mmhy affirm that ft.I..ad.unn leading agency for the performance of
a> use wast far which this permit is issued(Sec 3091.Civ.C.)
W�ALendch Nun.
z fenders Address
U Q 1 eerdfy that I have read thin a,Rcawr am mute Mau tionaMw Inferential..Is
IL^ conm I agora in comply with all city and county ordinances and sum laws tclaung is
C Wildingconstruction,and Mmby adman rtprtsentstivca of this city to enter upon the
WaMve-menior�Property fa inspection purposes
y (We)agree to new,indemnify and yeep harmless,the City of Cupertino again,
v<y liabilialmJudgments,case and capensee which may N my way weave agaiul said Lily
() in consequence of the it un ing of this Permit. j �t
APPLICANT UNDERSTANDaS AND ILL COMPLY WITH AI,L NOt1-POINT Issued by: Date 7 V
5 CE REGUTA71NOt I ` Re-roofs
����� (f
Signar3ea AppOnm/Conuacnr faro od
V HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or(inureWilding occupmt Bae arhmdle huallous maundal
u dented by IM CupeNno Municipal Code.Chapter 9.12.ad tM Health ad Safety
case,mecum sss3xa)7
❑Yos 14No// All roofs shall be inspected prior to any roofing material being installed.
Will the applicmt or future Wilding occupant use equipment a devices which If a roof is installed without first obtaining an inspection,I agree to remove
khuardnns air contaminants u donned b Bay Area Air Quality Manage mens all new materials for inspection.
i xrt
Oyes
Ihave mad thehaaNmsm 5585. 5533 aden534.I understood!
rite Wilding rf ll O
cat Health&Safety Cade,ScNnnsnd I,I.my responsibility
in Mary thulldon Wilding
Jena Mw
how"
tenml that It I.nY rospansiMlltY b mtifY the accupmt of are
mmnhmbe �`-\' ""'aorampm)y. Signature fApplicant Date
re agem h eN Dam All roof coverings to be Class'�W'or better
CITY OF CUPERTINO
• 2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35702028. 00
DATE ISSUED. . . . . . . : 04/28/2008
RECEIPT #. . . . . . . . . : BS000004601
REFERENCE ID # . . . : 08040200
SITE ADDRESS . . . . . : 10240 MIRA VISTA. AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : OLSEN MELVIN N AND KRISTINE A
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : SARATOGA CA, 95070-3003
RECEIVED FROM . . . . : JAMES HIRSCHBEK
CONTRACTOR . . . . . . . : JAMES HIRSCHBEK LIC # 24740
COMPANY . . . . . . . . . . : CAL-PRO ROOFING
ADDRESS . . . . . . . . . . : 2914 UNION AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95124
TELEPHONE . . . . . . . . : (408) 460-1976
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 7, 000. 00 0.70 0. 00 0.70 0. 00
1REROOFRES SQ FEET 20. 00 260. 00 0. 00 260. 00 0. 00
---------- ---------- ---------- ----
TOTAL PERMIT 260.70 0. 00 260.70 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
------ --------------- --------------------
CASH 260 .70
---------------
TOTAL RECEIPT 260.70
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- ------ ----------------------------
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
•
olo4 o 2-C
CITY OF CUPERTINO
REROOF
•CUPEkTINO PERMIT APPLICATION
APN # oa Oa� . l�� Day 28 20og
Building Address: i
Owner's Name: Phone #:
0 4 �0 8 —6 ,5-E I4g3
Contractor: Phone #:
C.Q I Q P_v oJ ` �j Fax #:
Cupertino Business License #: Contractor License #:
CR 40
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles al Asphalt Shingles
pc Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other (Specify) ❑ Other (Specify)
Number of existing coverings ❑ Provide I.C.B.O. Report#
❑ To be Removed ❑ Provide Mfgr. Installation Specs.
Job Description: `` I
a � kA � - Qe � I � Ce VV 1' �n 30
os b c��� �_ _�7-0 y I; $RpS ; d 0 �� % p
Residential Commercial Lj
Green Building: Please complete relevant portion of the Confirmed with Planning Dept. if
Green Building Checklist & attach it to the there are any restrictions: ❑
application or if applicable, include in plan
set & the sheet index.
Valuation: Z o p ,, o O
• I Have Read, Understand and Will Comply with Cupertino's Tear-Off Policy:
Signature o
CITY OF CUPERTINO
af - REROOF
IOCUPEkTiNO FEE SCHEDULE
Number of Fee ID Fee Description Fee Permit Type
Squares Group
1RER00FC0M Re-roof Commercial B ICOMMLROOF
1BSEISMICO Seismic Commercial B
ap 1RER00FRES Re-roof Residential B ISFDWLROOF
/ 1BSEISMICRE Seismic Residential B
1REROOFMRES Re-roof Multi-Family B 1MFDWLROOF
IBSEISMICRE Seismic Residential B
1BUSLIC Business License B
•
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
• Telephone: (408)777-3228
Fax: (408)777-3333
Building Department
Subject: Re-roofing policy for the City of Cupertino
1. Prior to permit issuance,you must agree to comply with 1997 UBC Standards
and manufacturers specifications on re-roofing.
2. New roof coverings shall not be applied without first obtaining all inspection
and written approval from the building inspector. A final inspection and
approval shall be obtained from the building inspector when the re-roofing
is completed.
3. All roofs shall be inspected prior to any roofing installation.
4. To receive a final sign off from the City, the following steps are
required:
1) Pre-inspection and/or tear off approval.
2) In-progress inspection approval.
3) Final inspection approval.
a) Spark arrester installation.
5. If plywood is installed, a plywood nail inspection is required.
. 6. Any roofing which is applied without first obtaining an inspection,
will require the removal of all new material down to the sheathing,
so a proper City inspection can be performed.
7. NOTE: If you call for a plywood nail inspection and the job is not ready,
you will be charged a re-inspection fee of$176.18. The re-inspection fee must
be paid before another inspection can be scheduled.
IMPORTANT:
1. Flat roofs must have a minimum of Y4" per foot slope and demonstrate
that there is no ponding.
2. An I.C.B.O. report is required to be on the job site at the time on inspection.
I understand and will comply withthe above stated policy on re-roofing./
Homeowner's Name: n 1 'sael 1'
Job Site Address: d3, `Y' 0 )"1 1'k, A V S
p i
Roofing Company Name: C � I— + p,',� � b r Uoy,
Applicant's Signature: WAA Itl Date:
• Greg Casteel
Building Official
Revised 11/2/04
Green Building Plan Check
Index of Green Building Points/Categories
A. Category Example of an Index or Table of Green Plan Sheet or Page Points
Building Points Categories that must be
shown and referenced on the Project
Plans See below
e
B. Site 9. Install H.E. Irrigation, (details/spec)' L-1 2 points
11. Permeable Paving, Note L-1 2 points
C. Foundation 1. Use 15% Flyash Concrete, (note) S-1 5 points
D. Structural 3. Uses Wood I-Joist, (See Spec.) S-2 2 points
5. Use Truss with heels, (detail) S-2 2 points
6. B. OSB Sheathing, detail S-2 2 points
E. Ext. Finish 1. Composite Decking, (Note/Spec.) A-3 2 points
4. B. Fiber Cement Siding, (Note/Spec. A-4 2 points
F. Plumbing 1. Insulate all H.W. pipes, (Note/Spec.) P-1 2 points
5. Tankless W.H., (Note/Spec.) A-2 2 points
11.A 2500 Gal. Tank, (Note/Spec L-1 10 points
G. Electrical 4. E. Ceiling Fans, (Note/Spec.) A-3 4 points
H. Appliances 1. Energy Star Dishwasher, (Note/Spec.) A-3 1 point
3. Enerqv Star Refrigerator, (Note/Spec. A-3 1 oint
P. Other 1. List Green Features on Plans A-1 1 point
TOTAL POINTS 40 points
4f (A-i.,ro
•
Plan Review Process Work Book Page-12-Revised 3/25/08
Green Points Rating System for Remodeling Projects
Due to the diversity of remodeling project types,assigning a"total points"value to a project to be considered environmentally friendly is
• not feasible.However,25 measures have been highlighted to signify that every effort should be made to incorporate them into your
projects. These items have been chosen based upon their impact on the environment and the health of the home in coordination with
ease of implementation and relative low cost. These measures can be used as a starting point for'greening'your project.
INPUT ReSDUrCeS Energy AID/Health
to
1.Recycle Job Site Construction&Demolition Waste
65%=1 point;75%= 2 points;BO%=4 points up to 4 Resource pts 0
2.Selvage Reusable Buildlhg Materials 4 Resource pts y=yes 0
3.Remodel for Mixed Use,Adaptive Reuse,and
Historic Preservation 4 Resource pts y--yes 0
4.Protect Native Soil 2 Resource pts y=yes 0
5.Minimize Disruption of Existing Plants 6 Trees 1 Resource pt y=yes 0
6.Implement Construction Site Stormwater Practices 2 Resource pts y=yes 0
7.Protect Water Quality with Landscape Design 2 Resource pts y=yes 0
R.Design Resource-Efficient Landscapes and Gardens ] 4 Resource pts y=yes 0
9.Reuse Materials/Use Recycled Content Materials
for Landscape Areas 2 Resource pts y=yes 0
10.Install High-Efficiency Irrigation Systems 2 Resource pts y=yes 0
11.Provide for On-Site Water Catchment/Retention 2 Resource pts y=yes 0
1 1 1
B.Foundation
1.Incorporate Recycled Flyash in Concrete
• 25%Recycled Flyash=2 points;Add 1 point for every 10%
increase of flyash,up to 5 points up to 5 Resource pts 0
2.Use Recycled Content Aggregate 2 Resource pts y=yes 0
3,Insulate Foundation/Slab before backfill 3 Energy pts y=yesl;;F 0
mm1
C.Structural Frame
1.Substitute Solid Sawn Lumber with Engineered Lumber 1 3 Resource pts y=yes 0
2.Use FSC Certified Wood for framing
(For every 10%of FSC lumber used=2 points,up to 10) up to 10 Resource pts. 0
3.Use Wood I-Joists for Floors and Ceilings 2 Resource pts y--yes 0
4.Use Web Floor Trusses 2 Resource pts y=yes 0
5.Design Energy Heels on Trusses 6'or more 2 Energy pts y=yes 0
6.Use Finger-Jointed Studs for Vertical Applications 2 Resource pts y=yes 0
7.Use Engineered Studs for Vertical Applications 2 Resource pts y=yes 0
B.Use Recycled Content Steel Studs for Interior Framing 2 Resource pts y=yes 0
9.Use Structural Insulated Panels(SIPS)
a.Floors 3 Energy pts y=yes 0
b.Wall 3 Energy pts y=yes 0
c.Roof 3 Energy pts y=yes 0
10.Apply Advanced Framing Techniques 4 Resource pts y=yes 0
11.Use Reclaimed Lumber for Non Structural Applications 3 Resource pts y=yes 0
12.Use OSB
a.Subfloors 1 Resource pt y--yes 0
• b.Sheathing 1 Resource pt y=yes 0
1 1 1
114pul Resources Energy 1ADIficafth
. xter or n e
1.Use Sustainable Decking Materials
a.Recycled content 3 Resource pts y--yes 0 •
b.FSC Certified Wood 3 Resource pts y=yes 0
2.Use Treated Wood That Does Not Contain Chromium/Arsenic 1 IAO/Health pt y=yes 0
3.Install House Wrap under Siding 1 IAO/Health pt y=yes 0
4.Use Fiber-Cement Siding Materials 1 Resource pt Y_—Yes 0
1 1 1
E.Plumbing
1.Install Water Heater Jacket 1 Energy pt y--yes 0
2.Insulate Hot end Cold Water Pipes 2 Energy pts Y--yes 0
3.Retrofit all Faucets and Showerheads with Flow Reducers
a.Faucets(1 point each,up to 2 points) Up to 2 Resource pts. 0
b.Showerheads(1 point each,up to 2 points) Up to 2 Resource pts. 0
4.Replace Toilest with Ultra-Low Flush Toilets
(1 point each,up to 3 points) Up to 3 Resource pts. 0
5.Install Chlorine Filter on Showerhead 1 IAO/Health pt y--yes 0
6,Convert Gas to Tankless Water Heater 4 Energy pts y=yes 0
7.Install Water Filtration Units at Faucets
(2 points each,up to 4 points) Up to 4 IAO/Health pts. 0
8.Install On-Demand Hot Water Circulation Pump 4 Resource pts Y--yes 0
r-.eiecmcar
1.Install Compact Fluorescent Light Bulbs(CFLs)
(6 bulbs=2 points,10 bulbs=3 points,12 bulbs=4 points) Up to 4 Energy pts. 0
2.Install IC-AT Recessed Fixtures with CFLs(1 point each,up to
5 points) Up to 5 Energy pts. 0
3.Install Lighting Controls(1 point per fixture,up to 4 points) Up to 4 Energy pts. 0
4.Install High Efficiency Ceiling Fans with CFLs
(1 point each,up to 4 points) Up to 4 Energy pts. 0
1 1 1
G.Appliances
1.Install Energy Star Dishwasher 1 Energy pt y=yes 0
2.Install Washing Machine with Water and Energy
Conservation Features 1 Energy pt y=yes 0
3,lnstall Energy Star Refrigerator i Energy pt y=yes 0
4.Install Built-In Recycling Center 3 Resource pts y--yes 0
H.Insulation
1.Upgrade Insulation to Exceed Title 24 Requirements
a.Walls 2 Energy pts Y_—Yes 0
b.Ceilings 2 Energy pts y=yes 0
2.Install Floor Insulation over Crawl Space 4 Energy pts Y--yes 0
3.Install Recycled-Content,Fiberglass Insulation with
No Added Formaldehyde 31A0/Health pts y=yes 0
4.Use Advanced Infiltration Reduction Practices 2 Energy pts y=yes 0
5.Use Cellulose Insulation
a.Walls 4 Resource pts y=yes 0
b.Ceilings 4 Resource pts yeses 0
6.Alternative Insulation Products(Cotton,spray-foam) o
a.Walls 4 Resource pts y=yes 0
c.Oemngs 4 Resource pts y=yes 0
INPUT Resources Energy AWHealth
In ows
l.Install Energy-Efficient Windows I
• i a.Double-Paned 1 Energy pt y--yes 0
b.Low-Emissivity(Low-E) 2 Energy pts y=yes 0
c.Low.Conductivity Frames 2 Energy pts y=yes 0
2.Install Low Heat Transmission Glazing 1 Energy pt y=yes D
1 1 1
J.Heating Ventilation and Air Conditioning
1.Use Duct Mastic on All Duct Joints 2 Energy pts y=yes 0
2.Install Ductwork within Conditioned Space 3 Energy pts y=yes 0
3.Vent Range Hood to the Outside 1 IAQ/Health of y--yes 0
4.Clean all Ducts Before Occupancy 2 IAQ/Health pts y=yes 0
5.Install Solar Attic Fan 2 Energy pts y--yes 0
6,Install Attic Ventilation Systems 1 Energy of y=yes 0
7.Install Whole House Fan 4 Energy pts y=yes 0
S.Install Sealed Combustion Units
a.Furnaces 31AQlHealth pts y=yes 0
b.Water Heaters 3 IAQ/Health pts y=yes 0
9.Replace Wall-Mounted Electric and Gas Heaters with
Through-the-Wall Heat Pumps 3 Energy pts y=yes 0
10.Install 13 SEER/11 EER or higher AC with a TXV 3 Energy pts Y_–Yes 0
11.Install AC with Non-HCFC Refrigerants 2 Resource pts y=yes 0
12.Install 90%Annual Fuel Utilization Efficiency(AFUE)Furnace 2 Energy pts y=yes 0
13.Retrofit Wood Burning Fireplaces
• a.Install EPA certified wood stoveslinsens 1 IAQ/Health pt y=yes 0
b. InstalVReplace Dampers 1 Energy pt y=yes 0
c.Install Airtight Doors 1 Energy pt y=yes 0
14.Install Zoned,Hydronic Radiant Heating 3 Energy pts y=yes 0
15.Install High Efficiency Filter 4 IAQ/Health pts y=yes 0
16.Install Heat Recovery Ventilation Unit(HRV) 5 IAQ/Health pts y=yes 0
17.Install Separate Garage Exhaust Fan 3 IAQ/Health pts y=yes 0
1 1 1
K.Renewable Energy and Roofing
1.Pre-Plumb for Solar Water Heating 4 Energy pts y=yes 0
2.Install Solar Water Heating System 10 Energy pts y=yes 0
3.Pre-Wire for Future Photovoltaic(PV)Installation 4 Energy pts y=yes 0
4.Install Photovoltaic(PV)System
(1.2 kw=6 points,2.4 kw=12 points,3.6 kw=16 points) Up to 16 Energy pts 0
6.Select Safe and Durable Roofing Materials —� 1 Resource pt y=yes 0
7.Install Radiant Barder 3 Energy pts y=yes 0
1 1 1
L.Natural Heating and Cooling
1.Incorporate Passive Solar Heating 5 Energy pts y=yes 0
2.Install Overhangs or Awnings over South Facing Windows 3 Energy pts y=yes 0
3.Plant Deciduous Trees on the West and South Sides 3 Energy pts y=yes 0
t 1 1
•
INPUT Resources Energy MOtHealth
. n oor r us ty en n s es ..
1.Use Low/No-VOC Paint 1 IAO/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAO/Health pts y=yes 0 .
3.Use Low/No VOC Adhesives 3 IAO/Health pis 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 6lA0/Hsalth pis y=yes 0
6.Use Exterior Grade Plywood for Interior Uses i IAO/Health pts y=yes 0
7.Seal all Exposed Particleboard or MDF 4 IAO/Health pts y=yes 0
B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0
10.Install Whole House Vacuum System 3 IAO/Health pis y--yes 0
1 I 1
N.Flooring
1.Select FSC Certified Wood Flooring 6 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 IAOMealth pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y--yes 0
6.Install Recycled Content Carpel with Low VOCs 4 Resource pts y--yes 0
1 1 1
Total o ntsvat a e: 1 1401 130 57
Total Points Project Received: 1 D 0 0 0
G:data/pmgsrgreenbuildngguidelineshemakleNgrempdntsfne1212.04proimed.ds
i
Community Development
10300 Torre Avenue
✓' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
I�UPERJTINO
Building De artment
JOB ADDRESS: PERMIT #
0kVC< 6 '-av
OWNER'S NAME: (S PHONE # d'R 114(1 /
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
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 Dat