09080027 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22001 LINDY LN C:)NTRACTOR:CRITCHFIELD PERMIT NO:09080027
C,)NSTRUCTION
O;"*vF,R'S NAME: TOM&HEMAL SURRETTE
8,'S S MCGLINCY LN DATE ISSUED:08/06/2009
(r. .:.R'S PHONE: 4039969510
CAMPBELL,CA 95008 PHONE NO:(408)371-3777
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r- PLUMB
License Class Lic.# �� MECH r RESIDENTIAL COMMERCIAL
Contractor r tC,1 T Date �'>_Q �Qq
JOB DESCRIPTION:OWNER SIDE OF GAS,LINE TRENCH,GAS LINE,
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 GAS
(commencing with Section 7000)of Division 3 of the Business&Professions F RESSURE TEST FOR METER RELEASE
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
1 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 �,q,Ft Floor Area: Valuation:$3000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued CPN Number:35627002.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that 1 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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnity and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non- oint source regulations per the Cupertino Municipal Code,Section Date:
9.18. Issued byo- �_
Date —�
Sif—tine
❑ OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
1 hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
I,as owner of the property.or my employees with wages as their sole compensation, Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044, signature of Ap licant:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker's 1 have read the hazardous materials requirements under Chapter 6.95 o the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the
compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued.
Safety Code,Section should 1 store handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by I use eq
Additionally,should use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
1 certif-that in the performance of the work for which this permit is issued,1 shall Health&Safety Code,Sections 25505,25533,and 25534.
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 Owner or authorized agent: Date:
become subject to the Wcrker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
1 certify that 1 have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
L11 ',e above mentioned property for inspection purposes.(We)agree to save Lender's Address
i fy and keep harmless the City of Cupertino against liabilities,judgments,
cu3Nta,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date__
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
00
Owner's
Owner's Name:TP,M 1��k &izL Phone#: 0(q Ce 01 rJ t
Contractor: (� Phone#: 40 S1 1 - ',z -)
C_)L� C1(L\ \ �> Fax #: 0, - 3 I `'-'�S
Contact: �_- -)C�\ U\v--\ Phone#:4D<K - -4q 1
&ULI�W fflcknaqp� Fax#: -4
Contractor License#: -1 1 �>3
Cupertino Business License#:
Job Description: �)tunee_ S`d�,� D Lh, 1
vb �veru vQ_ �:
Residential �� Commercial ❑
ValuatiorA
ZDC�)t O
Project Size: Express Standard Large Major ❑
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set&: the sheet index.
Green Building Points:
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
1BPREPIPE Commercial rc-pipe per fixture P 1CPRP
1PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1 BSEISMICOM Seismic Commercial P
Revised 01/07/09
CITY OF CUPERTINO
`- REPIPE/SEWEE MAIN SERVICE
CUPITYEf�TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
% 1BCBSC Cal Bldg Standams Commission B ALL PERMIT
` Fee TYPES
/ 1BSEISMICR Seismic Residential P
1PRSEWER Residential buil&ig P 1RPSS
sewer/sanitary sewer
1PRREPIPE Residential re-pip.-per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1PCESS Cesspool P
1 BPWATER Install/alter Watei Pipe P
1 BPFIXTURE Plumbing Fixture P
/ 1 PGASRES Residential Gas Piping System P
/ 1-4 Outlets
1 BPGAS Gas Piping System 5+ Outlets P
1PPERMITFEE Plumbing Permit Fee Issuance P
1PLMBLNCK Plumbing Plan Clieck P
1PLMBINSP Other Plumbing/gas Insp. P
1TRAVDOC Travel & Documentation Fee B
1 BUSLIC Business License B
INPUT Resoirces Energy 1ADMealth
M.Indoor Air Quality and Finishes
1.U3seiv"o-VOC Pah I IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes i IAQ/Health pts y=yes 0
3.Use Lowft 1100 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 31AQ/Health pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7.Sad 4 Oposed PArkialmW 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=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 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 .f Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y—yes 0
Total Points Available: 1 1401 1301 57
Total Points Project Received: 01 OF-71
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G:data/progs/gre:nbuildngguidelines/remodelers/greenpointsfinal2.12.04protected.xls
Community Development
10300 Torre Avenue
x Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
'UPERTINO
Building Department
JOB ADDRESS: PERMI #
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OWNER'S NAME: q- PHONE # -4-1--7 -
GENERAL CONTRACTOR: FAX#4 - -
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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
C6 Co -Oc-�
Owner ontractor Signature Date