05020109 CITY OF CUPERTINO i,� sew„ `nom
BUILDING DIVISION � PERMIT �CONTRAC7ORANTORMAT7ON
BUILDING ADDRESS: A PERFECT CLIMATE PERMIT Nb502O1O9
P0144 nRMP.CTF.R All
NER'S NAME: PERMIT ISSUE DATE
OW
JON NYGAARD 10570 S DEANZA BLVD 02/15/2005
lip ONE: SANITARY NO. CONTROL NO.
(408) 861-9545
ARClUTECrIENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MEC14
0 0 0 0
foo LICENSED CONTRACTOR'S DECLARATION I ]Ob Description
G 1 hereby.(Firm that I am licensed under provision nr Chapmr 9(commencing P
U with Section 7") f Diviaion J of he Business Professions Code.and my license is
'o ad in bull raroe and Off 12 REPLACE FURNACE & ADD A/C
jut? License Clazs Lic.N -
r Date Contractor
A RCHriECTS DECLARATIO
f w rsaaz V I undersand my plans shall W used public meards
0.O a.
G Licensed Professional
3 OWNER-BUILDER DECLARATION
<X I hereby affirm that I am exempt from the Commetor's License Law for the '
00 following mason.(section 703 1.5,Business and Profcstion Calc:Any city or county
m which requires a Permit in construct,aper,improve,demolish,or Srepair any structure 8408446206
zi pnorusitsissuance.alsorequims@capplicam forsuch permiuo flcasignedua¢mem
< to[heisliccnsedpursuantintheprovisionsoftheCnntmorer'sLicensefaw(Chapter9 Sq. Ft. Floor Area Valuation
nHn (commencing with Section 7")of Division 3 of the Business and Professions Code)us
5$
that he is exempt Ncmfrom and the basis for NO alleged exemption.Aoy violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil Penalty of 37��e1ane 00 Occupancy Type
not moa than 0vo hundred dollars(geese). P Y YP
❑1,ax owner of the property,or my employees with wages As dmir.mle compensation,
will do the work,and Be swaute is not immided or offered for sale(Sec.704,5,Business
and Proreulons Code:TM1t Contractor's License Law doe.not.poly to an owner of Required Inspections
property whobailds or improves 0ereon..nd who docasuch work bar.](.,Ihroug1b his
htun employees,provided that such improvements are not intended or offered for sale.IL
owever.the building or improvement is sold within one year of completion,Ne owner.
builder will have the burden of proving that he did not Wild at improve for purpose of
❑construct
owner of project
property,,Business udusi and Paarabions with licensed eunactors i-
coax La shoes not t(Sec.to an
prop Professionsds oripro Contractors nd ktlH@Wy �
c IawdocenmApply man with
3 COfpapeny who licensed pursuant
theme .and
who contracts for pmjec.with n comranor(q licensed punuanuo Ne Conua<tofs
C3]amnse Law.
❑ am exempt^an-tler�See. .B&PCfor thismazOn ^/)�
S_?
O
wner y C Data
WORKER'$COMPENSATION DECLARATION
(hereby alRrm under penalty of perjury one at the following declarations: OpAft7�6 � .
Ina ve and will formain aCcni(cmc of the Labor
ode.xam for WorkRSCompcm
rk(r provided for by Smion 3700 of the labor Code.for the pcs(pmmantt of the
rk for which this Peemil is issued.
I have andwill maintain Workeh Compensation Insurance,as required by Section
00 of the labor Code,for the performance of the work for which Nis permit is issuedy Worker's Compensation Insurance cartier and Policy nu sWrtier. ! olicy No.:
CERT( C MCATEOF E%EM ON FROM WORK RS'
COMPENSA NINSURANCE
(This section need not W completed tribe permit is for one hundred dollars(5(00)
in,less.)
I testify re,in the performance of the work for which this permit is issued,1 shall not _
employ any Person in any manner an u in become subject 10 Workers'Compensation
Laws of California,Date
Applicanl
NOTICE TO APPLICANT:If.after making this Cenificals of Exemption.you should
become subject to the Worker's Compensation provisions of the labor Cade,you muss
Z forthwith comply with such provisions Or this permit shall W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
1 hereby alFism But Nem is•mmquninn lending agency for 0e performance of
1' the work fur which Ihix tis sed(Sec 3(19 I V*CJ
21 (miler's Name { ...�!
1 I�ndeis Address /O�Jl,(� h
,)Q 1 ceaifY�hzvc rCTA;s arlpfl uonin state(hal 0.above information is
y bonen.1 agree to comply with all city and county ordinances nd cute laws relating to
/
�U abovconstruction.
ing .nd hncbyauNorimapresecity mdo:etives of this city c
yabonmeNioned property for inspection purposes.
(We)agree Is save,indemnify and keep harmless the City of Cupertino agnins
fn Iiabilitim judgment.con.cad capeoses which may in any way acme against said City S
J Z in canequencc of the granting of this Permit.
^ APPLICANT UNDERSTANDS AND W COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEXGULATIONS.^ p
4L6r l.�a..A / o[.(, .c. J- /S-D� Re-roofs
S�of ApplicanttConaach" Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicam os future Wilding occupant atom or handle hazardous maanal
as defined by the Cupenlm Municipal,Calc.Chapter 9.12.and she Health and Safety
cattle.se res P41.Non 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑
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
mil hazardous air anmminan.As defined by the Bay Arca Air Quality Management all new materials for inspection.
Dislrin?
OYex '0
(have rtaJ the hasaNnus mamrials myuimmen.under Chhe Califon
niceSafetyunderatandutwiftWilding ilding
Joeamolcurtentlythave a"am.NatitismymsatmiM1ilitymnntilytthe acupemofthe
mquiambas which must be met pear In issuance or a Ccnifcate of Occupancy. Signature of Applicant Dale
Owner or authorized agent Date All roof coverings to be Class "B" or better
Community Development
10300 Torre Avenue
J• Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
�UPEkTINO
Building De artment
JOB ADDRESS: / PERMIT #
S
O 'd 20 / O
OWNER'S NAME: PHONE # -�
GENERAL CONT OR: 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
AN Tile
Owner/Contractor Signa ure Date
CITY OF CUPERTINO o7
o
FURNACE/AC
OUPINEkT
O PERMIT APPLICATION FORM
APN # Date:
47 — 07l 5 05
Building Addr s:
163 Ze Aw .-
Owner's e: Phone #:
C r: / Phone: License #: l
5 -Z2315?
Contact: Phone: Cupertino Business License #::,_
Bu in ermit Info:
Bldg Elect Plumb Mec
Job Desc iption:
e lace_ -,,.e
Residential V—L- --__.- u..:. :Commercial ❑
For Residential Installations:
ttic ❑ ls` floor ❑ 2"d floor❑
4dhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation
New installation Planning A roval Re uired ❑
Cost of Project- Type of Construction: Occupancy group:
/
I OZ)D
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Re lacement�2-
Qty.
i
Qty. f
A f e 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
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
75qPPE
RMlT
FEE Plumbin Permit Issue PLUMBING
BPERMFEE Bld Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License UILDING
CITY OF CUPERTINO
�m 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 2
Sec : Twp: Rng : Sub: B1k: Lot :
APN . . . . . . . . : 32647075 . 00
DATE ISSUED. . . . . . . : 02/15/2005
RECEIPT # • • . . . . . . . : 28617
REFERENCE ID # . . . : 05020109
SITE ADDRESS . . . . . : 10344 DEMPSTER AV
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : JON NYGAARD
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1223
RECEIVED FROM . . . . : A PERFECT CLIMATE
CONTRACTOR . . . . . . . : SMITH, BYRON E LIC # 21144
COMPANY . . . . . . . . . . : A PERFECT CLIMATE
ADDRESS . . . . . . . . . . : 10570 S DEANZA BLVD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . . : (408) 861-9545
®FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW DAL
--- ------ - -------- -- ----- ----- --- - - -- ----- -----
BREMAIRHAN NO.UNITS 1 . 00 10 . 26 0 . 00 10 . 26 0 . 00
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
BREMRECEPT NO. OUTLETS 3 . 00 3 . 60 0 . 00 3 . 60 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
BSEISMICRE VALUATION 11, 000 . 00 1 . 10 0 . 00 1 . 10 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 179 . 24 0 . 00 179 . 24 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----- - ----------- -- - --------- ----------------- -
CHECK 179 . 24 022260
TOTAL RECEIPT 179 . 24
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL