09060027 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �1` 'TRQ I� MTI�N:
BUILDING ADDRESS: PERMIT NO.
10911 YNA PASTUSZKA 09060027
OWNER'S NAME: PERMTT ISSUE DATE
SA CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 o a a
u o p LICENSED CONTRACTOR'S DECLARATION Job D6SCTlptlOn
m 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z
with Section 70(X0)of Division 3 of the Business and Professions Code,and my license is
Zo H in full force and effect. EXTNG FEATR r REPLCD
? License Class Lic.K
Dale Contractor
t— ARCHITECTS DECLARATION
C< I understand my plans shall be used as public records
�0.
4 O y Licensed Professional
n H� OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
t 9 which requires a permit to construct.alter,improve,demolish,or repair any structum
Zy prior to its issuance,also requires the applicant for such permit to file a signed statement
_< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
Yr (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 81000
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(SM.
❑I,as owner of the property,or my employees with wages as their sole compensation, 326350-` 0 . 0 0
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Cade:The Contractors License Law does not apply to an owner of q P
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
sale.).
I,as owner of the property,am exclusively contracting with licensed contractors to
cfttzuct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense Caw 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
COMPENSATION 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 Worker's Compen-
.don,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 required by Sccdon
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. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section creed not be completed if the permit is foronc hundred dollars($I00)
or less.)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in
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
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z~ CONSTRUCTION LENDING AGENCY
[~—t tom. 1 hereby affirm that there is a construction lending agency for the performance of
p;> the work for which this permit is issued(Sec.3097,Civ.C.)
0 Lenders Name
Z Lenders Address
U 0 1 certify that 1 have read this application and state that the above information is
II+" coecct.1 agree to comply with all city and county ordinances and state laws relating to
0 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
huh liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. Date Z_►" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE
Dille Type Of Roof
MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by ft 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.
❑Yes "Io
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
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 dtc Califor-
nia Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant or the
require ts which must bWct prior to issuance of a Certificate oyoeeyp . Signature of Applicant Date
or � Date All roof coverings to be Class'�W or better
Owner authorizeagent �
�)W� 00,z7
CITY OF CUPERTINO
FURNACE/AC
CUPEI�TINO PERMIT APPLICATION FORM
APN # L Date:
(� �0. 0c )
Buildin Address: _
g A W 0
Owner's
Contractor License#: Cupertino Business License#:
Contact: Phone#:A o& qR8-
Fax #:
Building Permit Info:
Elect [ Plumb ❑}--- Mech r_
Residential �4 Commercial ❑
Job Description: ����
�e X 15TW 6C Hl �nT- �Z K6)
For Resi ential Installations:
Attic 1St floor [] 2°d floor ❑
Adhere to minimum setback requirement ❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction (Usage Class):
/06,2 U 9
Strapped On Platform Bonded New Location LJ Replacement
Project Size: Express ® Standard ❑ Large ❑ Major❑
Valuation:
Green Building: Please complete relevant portio n of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index. �\!
Revised 01/07/09
CITY OF C UPERTINO
FURNACE/AC
CUPEOF
Q INO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
FURNACE FURN/AC
1MCRAA Commercial-Repair/Alteration/Add to M
ea heating applialce,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,absorption or
evaporative cooling system,incl
installation of controls regulated by this
code.
1MCREPALT Commercial for the repair of alt/add to M
ea heating applia:ice,refrigeration
unit,cooling unit,VAV boxes,
absorption unit or ea heathing, cooling
absorption,or evE porative cooling sys,
incl install of cor.trols regulated by
this code.
1MCSUSHTR Commercial Install/Relocate ea M
suspended heatei,recessed wall htr, or
floor mounted ur.it heater.
1PGASCOM Commerical for oa gas piping System P
1-4 outlets
1 BPGAS For each gas piping system of 5 or P
more per outlet.
1 MCAPPVNT Commercial for 1 he install/relocate/ or M
replacement of e i.appliance vent
installed & not incl in an appliance
permit.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Commercial Sei.,mic B
1 MRRAA Residential RepE it/Alteration/Add to M
ea heating applience,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,,ibsorption or
evaporative cooling system,incl
installation of ccntrols regulated by
this code.
1MRSUSHTR Residential Install/Relocate ea M
suspended heate.-,recessed wall htr, or
floor mounted wait heater.
CITY OF CUPERTINO
11 SIN-- FUR1114ACE/AC
CUPEt�TINO FEE SCHEDULE
Quantity Fee ID Fee Deseriplion Fee Permit Type
Group
1 MRAPPVNT Residential fo,-the install/relocate/or M
replacement of ea appliance vent
install ¬ i icl in an appl permit.
FURNACE FURN/AC
1 PGASRES Residential for ea gas piping system of P
1-4 Outlets
1BPGAS For each gas piping system of 5 or P
more per outlet.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1 BSEISMICR Residential Scismic B
1 MECPLNCK Mechanical P.an Check M
1MFR=<100 Furnace Syst =100k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance up to and
include 100,0)0 Btu/h
1 MFRN>100 Furnace Syst > 100k BTU install or M
relocate ea fo:•ced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance over
100,000 Btu/li
IEPERMITFEE Electric Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
I
1PPERMITFEE Plumbing Permit P
1 TRAVDOC Travel Documentation B
1 BUSLIC Business Liccnse B
A.Indoor Air Quality and Finishes
1.Use ILMAilo-VOC P18" 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes ?IAQ/Health pts y=yes. 0
3.Use Lowft 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 al d P and or 1ADF 4 IAQ/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 IAQ/Health pts y=yes 0
. 1 i !
N.Flooring
1.Select FSC Certified Wood Flooring EI 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 3)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 4Resource pts y=yes 0
. ! 1 !
Total Points Available: 1401 130 57
Total Points Project Received: r 0 O=
v
G:data/progslgre:nbuildingguidelines/remodelers/greenpointsfinal2.12.D4protected.xls
Community Development
10300 Torre Avenue
1,7.
,2 Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
TPEkTINO
Building Department
JOB ADDRESS: `Q511 � PERMIT # 0�
OWNER'S NAME:
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
Signature Date