05100162 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �.kgoNTRACTORINFORMATION
xray of �. i. .a:.
BUILDINGADOREss: AIR QUALITY HEATING & AIRC fK111N10S100162
OWNER'S NAME: PERMIT LSSUE DATE
PLC= mnown 714 NO THRUP ST 16
NE: SANITARY NO. CONTROL NO.
(408) 293-7138
ARCHITECGENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 (�
U00 LICENSED CONTRACTOR'S DECLARATION lob Description
i C I hereby affirm Nat 1 am licensed under provisions of Chapter 9(commencing P
�xw with Scotian 70(10)of Division 3 of the Businu and Professions Code.and my license is ,1 f
o in full fame and effect p
ZEl'n Date,
z1 can" ry � NEW FURNACE
L � Da¢ IO�IiO a�-5 can" H�Y�UGla�i! PF�p /s�C
n ARCHITECTS DECLARATION
4.< 1 understand my plans shall hr used ea Public cords iVF)
JyU
;un Licensed Professional SUpG
g Oat I am exempt
from
mDECLARATION
Ea F I harry affirm that 1 em cxcmpt Tram Ne Contractor's o License Law for the IP P
p o fallowing mason. ercdan]IDLA Business end Professions Code:Any city or county
E
ie which squires a issuance.also ac conswd Mme improve,h Permit t ore a sig any structure,
. Zy
poortoas easedasSant tol2elheviion at fardue such Dfrmi'toices,LewdCmPUstatement
z��< that(commislianudPScetiolmNcofDivision ofUseBmcmraL¢nscLzw(Chapmr9 Sq.FL Floor Area Valuation
(commencing wisheadman told the
basis for
of NCBueinexe tendon.An ions CMT)or
i 3$ that he u exempt therefrom and tk bait for the alleged exemption.Any violation of
Section 703 1.5 by airy applicant for a Permit subjects the applicant to a civil penalty of 3 9,95TMi"er ane O 0 Occupancy T
not mom than five hundred dollars($500k P Y YPe
❑has he,of the property,or my employees with wag.a their sole compensstie..
will do the work and thm structure isnot intended or offered for sale(Sec.7044,Business
and Professions Code:The ContWIm`3 License Law does not apply to an owner of Required Inspections
property who builds or improves Hereon,and who does such work himself or through his
Own employe.,provided thatsuch improvementeare notinuuled orolfered forsale.If. + R
however,the building orimprovemu
ena sold within one year of comPlcdon.the owner. a �
builder will have the burden of proving that he did not build or improve for purpose of �
sale,).
❑L as owner of ct property..B exclusively conoaoing with:)ceased mrmcu wrs t.
clam,La Ne does
apply
to an Business and Professions ds or
The C r themon.Lt. 4t jf
cease ntr da.not apply to an owns of property who builds os improv.thrmon,and gts J�
whocontractsLa ta for projects with a mnaacmrts)limed pursuant w the ConuacmYs
License Isw.
❑l am tempt under Sec. ,B h P C far Ibis reason
R f
Owner Draw 17 l§ 1j r
WORKER'S COMPENSATION DECLARATION •, frL,`s40 �it
I hereby of ore under Penalty of perjury aoe 4
of the following declarations: ti�i.a'd
1 have and will maintain aCerificau of Consenuo self-insum for Worker's Compen- mow
sation,a provided for by Section 3900 of the Labor Cade.for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,a required by Section
3700 of the Le Wr Code,far the csfanniums,of dr work for which this permit is issued.
My Workers Compensation Insurance carrier sad Policy number arc:
Carrier.Fav m?f S W
�DOX"a, Policy Na: Q\CI5k 23
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section nerd notbremnplcmJ if the Permit is for one hundred dollars($100)
or less.)
1 certify that in the Performance of the work for which this Permit is issued.I shall not
employ any person in any manner an a m become subject to the Workcts Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Ceniftcate of Exemption.you aboard
become subject to the Worker's Compensation previsions of the Labor Code,you mum
.J O foMwith comply with such proximo.or Nis permi.hall W mrevoked.deeedrevoked.Z U; CONSTRUCTION LENDING AGENCY
F Ihereby alarm that there iso crommoctinn eedm,ii,cocy far the perraarnmoour
C4 the work fur which this permit is issued(Sce.3097,Civ.C.)
aQ tenders Name
Z Lenders Address
U Q 1 certify that 1 have mad this application and state that the above infamiaiun is
Hcorrect.1 agree to comply with all city and county ordinances and sum laws relating to
O V building construction.and hereby amhonxz rcPmsentmives of this city 10 cater upon the
H 1 have mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupcdino agaiat
h liabiLaost,judgments.costs and expenses which may in any way aceme against said City
U in consequence of Ne granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
pit .A�Lt a,�LLTn/ /-/z0/0'-_ Re-roofs
Srgnamreof ,dib nt/Comracmr Data
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant of Tamm building Occupant smm or handle handous material ,
a defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
races seoiea 25533(a>7
❑r. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building acupam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
Disoict7
ED yes
1 have mad the Wandous materials mquitemema under Crop.,6.95 ifthe Califon
nix Health&Selo,Code,Seromas 35515,25533 and 25534.1 Understand that if the Wilding
does not currently have a to ara,that it u my r.pansibilh,in Way the acupant or the
of cam which mum be met pri�or�w�rssuan�afa.Cenifieam of Occupanry.
/ M(0112 t L�I� r Signature of Applicant Dale
t (Ul zu
Owner or mumn. agent p All roof coverings to be Class "B" or better
CITY OF CUPERTINO
2 of 2 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35618069.00
DATE ISSUED. . . . . . . : 10/20/2005
RECEIPT #. . . . . . . . . : 31676
REFERENCE ID # . . . : 05100162
SITE ADDRESS . . . . . : 21723 CASTLETON ST
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : ELOISE O'DOWD
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4704
RECEIVED FROM . . . . : AIR QUALITY H & AIR
CONTRACTOR . . . . . . . : MATTHEW FARBER LIC # 22791
COMPANY . . . . . . . . . . : AIR QUALITY HEATING & AIRCON
ADDRESS . . . . . . . . . . : 714 NORTHRUP ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95128
TELEPHONE . . . . . . . . : (408)293-7138
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
__________ _____________ __________ __________ __________ __________ __________
BREMFURN NO UNIT 1.00 14 .31 0.00 14.31 0.00
BENERGY PERMIT FEE 1.00 34 .86 0.00 34.86 0.00
BSEISMICRE VALUATION 2, 800.00 0.50 0.00 0.50 0.00
PPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
EPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
MPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
---------- ---------- ---------- ---------- .
TOTAL PERMIT 164.78 0.00 164.78 0.00
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ------------ --__-_----___-____
CHECK 331.56 51837
TOTAL RECEIPT 331.56
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL
•
Community Development
v 10300 Torre Avenue
? zy' Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�IJPEkTINO
Building Department
JOB ADDRESS: PERMIT #
2-42 Castle--brt fit ; > .no CA R5614 2
OWNER'S NAME: _ / IJUwG( PHONE # �2 4?
GENERAL CONTRACTOR: Ay nua(, f( C FAX #
I am not using any subcontractors: at7/G call LaL22 -� Lc 2 40 5
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
O�Aer/ContractoiSignature Date
CITY OF CUPERTINO
FURNACE/AC
l;I I Y(11
cUPERTINO PERMIT APPLICATION FORM
APN # Date:
3s � --JSs - o� Io� Zo�os
Building Address: 5 o 1
�. ICC(
�23 S-1-letnr] Si-. G.t, 71.0, Ch `� 4
Owner's Name:_ Phone #:
"Lol SL b I70W 4b$-252-21-2(,
Contractor: License #:
Y iVl Y C&I
Contact: tI Cupertino Business License #:
va-W GN1 22�
Building Permit Info:
Bldg ❑ Elect 0 Plumb ❑ Mech ®'
Job Description:
ylXn
UJ �Vr CA ( p_ !G �C-Q—
Residential 7121)� Commercial ❑
For Residential In�llations:
Attic ❑ 1' floor 2nd floor ❑
Adhere to min set back requirement ED
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: Occupancy group:
OO or-
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING