09010052 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CREC �� r
BUILDING ADDRESS: PERMIT NO.
8191 HYANNI P RT DR HAGOS TEKLE CONSTRUCTION 09010052
OWNER'S NAME: PERMIT ISSUE DATE
SAN CONTROL NO.
ARCHIT FCrfENGINEER: BUILDING PERMIT INFO
REMODEL 8 0 SQ FT TO BLDG EO PLUMB M�ECH
.00 LICENSED CONTRACTOR'S DECLARATION BATHROOM NON—STRUCTU��t��-3EA;~'D
U I hereby affirm that I am licensed under provisions of Chapter 9(commencingeSCription
z with Section 7000)of Division 3 of the Business and Professions Code,and my license is
=H in full force and effei:6
Z License Class—� Lic.#'t,p Date — o Contractor L
AR HITECTS DECLARATION
iU I understand my plans shall be used as public records
L 4.w Licensed Professional
OWNER-BUILDER DECLARATION
.i I hereby atTi.that 1 am exempt from the Contractors License Law for the
y O O following mason.(Section 703 1.5,Business and Professions Code:Any city or county
4$ which requires a permit to construct.alter,improve,demolish,or repair any structure
n Z prior to its issuance,also requires the applicant for such permit to file a signed statement
F that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
X F a (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
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).
❑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 Contractors License Law does not apply 10 an owner of (1 p
property who builds or improves Urercon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.U.
however,the building or improvement is sold within one yen of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Conuaemrs Li-
cense Law 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 Contractors
[sense saw.
❑I am exempt under Set B&P C for this mason
Owner Date
WORKER'S COMPENSA77ON DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Warker's Compen-
....ton,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 Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued
My Workers Compensation Insurance carrier and Policy number are:
Carries: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This stiction need not be completed if the permit is fa one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,)shall not
employ any person in an r txottte attbt w tlt�Wgr�gg t yptpensalion
Laws of Califoroia Dan
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z tr CONSTRUCTION LENDING AGENCY
[�W 1 hereby affirm that there is a construction lending agency for the performance of
LY+5 the work for which this permit is issued(Sec.3097,Civ.C.)
WCL.A Lender's Name
] Lenders Address
V 0 I certify that 1 have read this application and state that the above information is
iL►" correct.I agree to comply with all city and county ordinances and state laws relating to
0U building construction,and hereby authorize representatives of this city m enter upon the
w above-mentioned property for inspection purposes
(We)agree to save,indemnify and kap harmless the City of Cupertino against
rF-t rA liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
-+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU REGULATIONS. A�5
c-- ' I Re-roofs
S ure o App icant/Contrsctor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
strict?
❑Yes ❑Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health do Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
Aga
cots which must be mel art to issuathee of a Certificate of Occupancy. Signature of Applicant Date
�® All roof coverings to be Class's''or better
mer or authorized agent Date'
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 35611024 . 00
DATE ISSUED. . . . . . . : 01/13/2009
RECEIPT #. . . . . . . . . . BS000006958
REFERENCE ID # . . . : 09010052
SITE ADDRESS . . . . . : 8191 HYANNISPORT DR
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : MCNULTY DANIEL A AND ARLENE D
ADDRESS . . . . . . . . . . : 8191 HYANNISPORT DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4063
RECEIVED FROM . . . . : HAGOS TEKLE
CONTRACTOR . . . . . . . : HAGOS TEKLE LIC # 30019
COMPANY . . . . . . . . . . : HAGOS TEKLE CONSTRUCTION
ADDRESS . . . . . . . . . . : 8791 FALLBRIGHT WAY
CITY/STATE/ZIP . . . : ELK GROVE, CA 95624
TELEPHONE . . . . . . . . : (408) 314-6475
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 35, 000 . 00 2 . 00 0 . 00 2 . 00 0 . 00
1BSEISMICR VALUATION 35, 000 . 00 3 . 50 0 . 00 3 . 50 0 . 00
1REMRESBAT SQ FEET 80 . 00 551 . 00 0 . 00 551 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 556 . 50 0 . 00 556 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 556 . 50 2176
---------------
TOTAL RECEIPT 556 . 50
Community Development
10300 Torre Avenue
,�SF ,
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
CUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
OWNER'S NAME: e PHONE #
GENERAL CONTRACTO : S 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
L-,- Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
X Linoleum/ Wood
Y Glass / Glazing
Heating
Insulation
rc Landscaping
r/ Lathing
(/ Masonry
Ornamental Sheet Metal
6--- Painting/ Wallpaper
X Paving
Plastering
(/ Plumbing
Roofing
Septic Tank
Sheet Metal
!/ Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
k ADDITION/REMODEL
CUPEkTINO PERMIT APPLICATION FORM
5L
APN # Date:
Building Address:
9(?i Clf
Mailing Address (if different from building address):
A IS ®e2+
Owner's Name: Phone#
-1943
Contrac or: _ Phone#:(-LFo 731 —6 L�7 5--
Fax #:
Contractor License#: C�3 /
Cupertino Business License#:
Contact: Phone#: c� � 3(L7` — 7 S`
lw&os Fax #:
Building Permit Info:
Bldg. ❑ Elect. Plumb. Mech. Hillside ❑
Job Description:
Addition-What is being added?(Be Specific):
What is being remodeled (not including additio )?
Remodel Includes ke-Roof: Yes ❑ No ® If yes list number of squares
Remodel Includes Structural: Yes ❑ No fA
Do you have the pre-application planning approval? Yes ❑ No
If yes, please provide a copy of your planning approval letter. Planners name:
Square Footage:
Addition: Porch: Deck: Garage: Detached Attached
Remodel: Kitchen BathX Other
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ IVIII B, IV-HT,V-B D-- V_ 3
Valuation: , Please check this box if the project is a
second-story addition ❑
Project Size: Express ❑ Standard ❑ Large ❑ Major❑
Please complete relevant portion of the Green Building
Checklist& attach it to the application or if applicable, Green Building Points Achieved:
include in plan set& the sheet index.
***For Office Use Only***
Over-the-Counter ❑ Revised 01/07/09
CITY OF CUPERTINO
ADDITON/REMODEL
FEE SCHEDULE
Quantity Fee ID Fee Description Fee Group Permit Type
Sq Ft
1 MECPLNCK Stand Alone Mechanical M
Pln Ck(hourly
1 PLMPLNCK Stand Alone Plumbing P
Pln Ck (hourly)
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fee
1BSEISMICRE Seismic Residential B
am--h �3Qmc)d-e-
LAP AID 3M -�-4--
1 TRAVDOC Travel & Documentation B
1BUSLIC Business License B
n
M.Indoor Atr ualdy an Ferns es
1.Use Low/No-VOC Paint 1 IAQ/Health pts y--yes; 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3.Use Low/No VOC Adhesives 3 IAQ/Health pts 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 61AQ/Health pts y=yes
0
0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes
7.Seal all Exposed Particleboard or MDF 4 IAQ/Health. pts y=yes 0
S.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 IAQ/Health pts y=yes 0
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring 8 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 IAQ/Health pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
! ! 1
Total Points Available: 140 130 57
Total Points Project Received: ? 01 0 0
G:data/progs/greenbuildngguidelines/remodelerslgreenpointsfinai2.12.D4protected.xis
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Assessor's Parcel Number:
Name of owner. � ik
Project address. 191 r1/
Contact person. Phone. C L1-OS2 31LT7�
Fax.
Net square footage of lot.
Existing Proposed
Square footage: First floor:
Second floor:
Garage:
TOTAL:
Are there at least two 10 foot by 20 foot clear spaces inside the garage? AY
LS privacy protection planting required for the project?
On what floor(s) is work being done?
Brief description of work. J2
Code edition4flM CBC (Y -N)�OCFC (Y -Nj6� CMC (Y-N)
CPC (Y- .) 0 NEC (Y-N)
Effective 1/1/08
Plan Review Process Work Book Page-B-Revised 1/1/08