09050139 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS:
T( PERMIT ISSUE DATE
OWNER'S NAME:
S A CONTROL NO.
PHO
BUILDING PERMIT INFO
ARCHITEC IENGINEER: BLDG ELECT PLUMB MECH
a 0 a 0
u o a LICENSED CONTRACTOR'S DECLARATION Job Description
V I hereby affirm that I am licensed under provisions of Chapter 9(commencing
:may n ullfoorceandeffettDivision 3ofthe Business��te .and mylicense is FURNACE & DUCT INSTALLATION — SKYLINE HEATING &
vg Z License s Lte•8
E„p Date Contractor
SHEET METAL, INC. — SKYLINE HEATING & SHEET
ARCHITECTS DECLARA ON
I understand m s shall be blit fetor METAL,
O Licensed Professional INCL PD FOR BUS LIC
OWNER-BUILDER DECLARATION
2<2 1 hereby alTirm that I am exempt from the Contractors License Law for the
OO following reason.(Section 7031.5,Business and Professions Code:Any city or county
e m which requires a permit to construct.alter,improve,demolish,or repair any structure
a"y prior w its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation
Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 )q
yF=- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y .. that he is exempt therefrom and lbe basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number
not more than five hundred dollars(5500)• 37537001 . 01
0 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 Required Inspections
and Professions Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sate.).
0 I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors 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
License Law.
0 I am exempt under Sec B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
T have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
m,as provided for by Section 3700 of the Labor Code,for the performance of the
..ork for which this permit is issued.
[have and will maintain Worker's 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 am:
Cartier. S��Policy No.12-29 3 I0�d .2.:?,-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section treed not be completed if the permit is for one hundred dollars(S 100)
or less.)
I certify that in the performance of the work for which this rmil is issued.I shall not
employ any in any man so come sub' the workers'Compensation
Laws of Cal'om' Dale
Applicant
NOTICE TO PLICANT:If,after making this Certificate of Exemption,you should
become iubj6ct to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions orthis permit shall be deemed revoked.
z 2CONSTRUCTION LENDING AGENCY
Fr V) I hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lenders Name
Lenders Address
U C) I certify that I have read this application and state that the above information is
LL E" correct.I agree to comply with all city and county ordinances and state laws relating to
8 U building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
CA liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
►+ APP ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: -L
SO E REGU if llt
lb I Re-roofs
Sig ureofApplican ontractor Date Type of F.00f
HAZARDOUS MATERIALS DISCLOSURE yP
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(a)? All roofs shall be inspected prior to any roofing material being installed.
0 Yes IP No
Will the applicant or future building occupant use equipment or devices which
If a roof:s installed without first obtaining an inspection,I agree to remove
-sit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
vitt? /
0 Yes ]
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does no urendy have a tenant,that it is my responsibility to notify the occupant of the
requi tc which et prior issuance of Certificate p ry. Signature of Applicant Date
All roof coverings to be Class`;r�.`'or better
Ownc or authorize agent Date
0
CITY OF CUPERTINO
FURNACE/AC
. .................
CITY OF
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
D c) Cil s if
Building Address:
u
Owner's Name: Phone#:
< C.
Contractor: Phone#:L ky
Fax #: c,
Contractor License#: Cupertino Business License#:
Contact: Phone
Fax #: 'i L
Building Permit Info:
Elect 2_____ Plumb Mech [:I
Residential El Commercial
Job Description:
For Residential Installations:
Attic 1:1 1" floor 2°d floor ❑
-Adhere to minimum setback requirement E]
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installatiorL ❑
New installation Planning Approval Required 0
Cost of Project: Type of Construction (Usage Class):
Strapped On Platform Bonced LT New Location Replacement
Project Size: Express [� Standard ❑ Large Major F]
Valuation:
Green Building: Please complete relevant portio:i of the Green Building Checklist & attach it to the
application or if applicable, include in plan set& the sheet index. 7,---
Revised 01/07/09
CITY OF CUPERTINO
FURNA►CEAC
CUPEkTiNO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
FURNACE FURN/AC
1 MCRAA Commercial-Rep,,Lir/Alteration/Add to M
ea heating appliar.ce,refrigeration unit,
cooling unit,absoiption unit,or ea
heating,cooling,absorpti on or
evaporative cooling system,incl
installation of controls regulated by this
code.
1 MCREPALT Commercial for the repair of alt/add to M
ea heating appliar.ce,refrigeration
unit,cooling unit,`/AV boxes,
absorption unit or ea heathing, cooling
absorption,or evaporative cooling sys,
incl install of controls regulated by
this code.
1 MCSUSHTR Commercial Install/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted unit heater.
1PGASCOM Commerical for e gas piping System P
1-4 outlets
1BPGAS For each gas piping system of 5 or P
more per outlet.
1 MCAPPVNT Commercial for the install/relocate/ or M
replacement of ea appliance vent
installed ¬ in(-.I in an appliance
permit.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Commercial Seismic B
1 MRRAA Residential Repai r/Alteration/Add to M
ea heating appliar.ce,refrigeration unit,
cooling unit,absoiption unit,or ea
heating,cooling,absorption or
evaporative cooling system,incl
installation of controls regulated by
this code.
1MRSUSHTR Residential Install/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted unit heater.
CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO FEE '�;SCHEDULE
Quantity Fee ID Fee Descrip tion Fee Permit Type
Group
1MRAPPVNT Residential for the install/relocate/or M
replacement of ea appliance vent
install & not incl in an appl permit.
FURNACE FURN/AC
1 PGASRES Residential for ea gas piping system of P
1-4 Outlets
1BPGAS For each ga:, piping system of 5 or P
more per outlet.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Residential Seismic B
1 MECPLNCK Mechanical Flan Check M
1MFR=<100 Furnace Syst<=100k BTU install or M
relocate ea fcrced-air/gravity type
furnace/burncr, incl ducts/vents
attached to such appliance up to and
include 100,000 Btu/h
1 MFRN>100 Furnace Syst> l 00k BTU install or M
relocate ea fcrced-air/gravity type
furnace/burricr, incl ducts/vents
attached to such appliance over
100,000 Btu/:
1 EPERMITFEE Electric Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Pe-mit P
1 TRAVDOC Travel Documentation B
1BUSLIC Business Licimse B
CITY OF CUPERTINO
T FURNACEAC
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
AIR FURN/AC
CONDITIONING
1 BCAIRHAN Commercial A/C Units <= l Ok CFM B
1MCRAA Commercial Mech Repair/alt/add M
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Seismic Commercial B
1PGASCOM Commerical for ea gas piping System P
1-4 outlets
1PGASRES Residential for ea gas piping system P
of 1-4 Outlets
1 BPGAS For each gas p:ping system of 5 or P
more per outlet. Comm/Resid
1BREMAIRHAN Residential A/C units <= IOk CFM B
1MRRAA Residential Mech Repair/alt/add M
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Resider.tial B
1 EPERMITFEE Electric Permit E
1 MPERMITFEE Mechanical Permit M
1PPERMITFEE Plumbing Permit P
1 TRAVDOC Travel Documentation B
1 BUSLIC Business Licens B
INPUT ResDurces EnergyIAO/Health
M.Indoor Air Quality and Finishes
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 LowlNo 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 6IAQ/Health pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7.Seal all Exposed Particleboard or MDF 4 IAQ/Health pts y=yes 0
8.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=yesJim
0
N.Flooring
1.Select FSC Certified Wood Flooring 3 Resource pts y=yes 0
2.Use Rapidly Renewable Flooring Materials f Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 1 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 1 Resource pts y=yes 0
Total Points Available: 140 130r- 57
Total Points Project Received: 01 0 0
G:data/progslgrei:nbuildingguidelines/remodelers/greenpointsfinal2.12.D4protected.xls
Community Development
�xw 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
%PEkTINO
Building Department
JOB ADDRESS:,,,,. PERMIT#
OWNER'S NAME: �YO( PHONE # ✓ �`
GENERAL CONTRACTOR: �, �� �;, FAX # " Y --
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSIISIESS 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 Date