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05070200 CITY-OFCUPEWrINO > ' BUILDING DIVISIONPERMITCONTRACTORINFORM'ATI , N k BUILDING ADDRESS: HUSSEY BROS INC PERMIT NO.05070200 ER'S NAME: PERMIT ISSUE DATE CATE THOMAS M AND EDNA P 640 TAYLOR AVE 07 /29/200S PHONE: SANITARY NO. CONTROL NO. (408) 733-6360 ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH _Nqo AL flog(_��po 0 lxpcp LICENSED CONTRACTOR'S DECLARATION Job Descri hong Q5,�f1 E ll ad C 1 Mrtby efrrm Nu 1 am lived under pmvision5 of Chapter 9(commencing - Dp [t tl cul I LIISo HL'�s'a iILJtl 'ci with Section 70kd.f Division 3ofihc Business and Professions Code.and my license is m in fullfnaeendcffeer.Ct,t0 Gs, REPLACE FURNACE & A/C pg? Llcenu'r'/'•�s�CO. Date t 1 ARCHITECT DIr ECLARATIONu_ 73 C I undcrseand my plans shall W used as public meet& 1k[� '6D ✓ULD c tV Licensed Professional a� `05 OWNER-BUILDER DECLARATION n��T,'i,�!,/, no 1 hereby affirm on 1 r.3 exempt from the Contractor's Co License Law Int the 00 which gmresa paccdun 7rl]LS,Business and improve. m'uns Code Any city or county $ wM1ich requires a pertnit m cov=et.alter,impmm.dcmolLxh,Or mpnir any l=essee $7600 u—to prior to its issuance,also inquires the applicant for such permit to rile aligned sediment that he is licensed purstionuothe provisions ofthe Consrncmr'sLianse Law(Chapter 9 Sq.Ft. Floor Area Valuation YF$ (commencing with Section 7WO)of Division 3 of the B usiness and Profeasions Codd)or y _ that be is exempt dMrcfrom and the basis for the alleged exemption.Any violation of Section 703 1.5 by any applicant for a permit subjects the applicant o a civil penalty of APW NUMEki; 0 0 Occupancy Type not max than five hundred dollars($500). ❑Lasownm of Ne propcny,mmy cmployca with wage utheir ale eompewdion. will do the west and the structure u notinxrWed or offered(orale Dec.7061,Business and Professions Coda:The Concocdorl Lice=law dors not apply to an owner of Required Inspections pmpeny who builds orimproves dmercon,and who kis such warkhimulf orthrough his own employ=,provided that such improvements art not intended moRered for We.IL howevu,the building or improvement is sold within and,leu of complation.Ne owner builder will have time burden of proving that he did not Wild or improve for purpose of ale.). O 1,as Owner of the prupeny,am exclusively contracting with licensed contractors to connroct the projeO(Sec.706,1.Business and Profeuiore Code:)The Comautor's Li cense raw does not apply to an owner of property who Wilds or impmves thereon.and who concocts for such projects with a co muntor(s)licensed pursuant to the Convutor's License Taw. ❑I am exempt under Sec. .B&P C for this reason Far Data WORKER'S COMPENSATION DECLARATION 1 hereby a fires under penalty of perjury one of Ne following declarations: I ham and will maintain a Certificate of Cmuent to ulbinsure fm Worka(sCompen- atian.a provided for by Section 3700 of the tabor Code,for IW pdrformance of the work for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance,as myvimd by Secuon 37W of the labor Code,for the perfarmaec of the work for which the permit is issued. My WmWx ComlJh'� ation Insurance nater and Policy number art: Cairier: �I`VCIC, �CATE F EXEMPTION Policy R.: WORKERS� CERTIFICATE OF COMPENSATION NFROM WORKERS' COMPENSATION INSURANCE (Tru section need not becompletoJ iDW permit is for one hundred dills($IN) or Ica.) 1 cm ifv that in the performance of the work for which this permit is issued,1 shall not employ any person in any manner u as w become Subject o the Workers Compevauon Laws of California.Data Applicant NOTICE TO APPLICANT:If.after making Nis Ceniftcate of Exmpdion,you should become subject to Ne Worker's Compensation provisions of the labor Code you must .J 0 sh forthwith comply with such provisions or this permit all W dammed revoked. Z" CONSTRUCTION LENDING AGENCY [—i T hereby affirm that there is a covtrurtinn lending agency for the performance of C4 7 the work for which this permit is issued(Sec.3W7,Civ.C.) iT] Lando',Name Lenders Address _D a7. V O 1 certify that I have read this application and sate that the about information is ly — trader.I agree to comply with all city and county drummers and sure laws elating to pU Wilding cowruction,did hereby mNorim¢preaenutivss of Nu city to enter upon the r~U abem ve- entioned property for inspection purpmcs. CL (We)agree to save,indemnify and keep harmless Ne City of Caption.against Frn liabilities,judgments,casts and expenses which may in any way accrue,thwart aid City V Z in crnxgmnete of date granting of this permit. APPLICANT UNDERST S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATION /m 2-9_0r IVa1 Re-roofs signature of ApplicaData HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF Will the applicant ser(mux building meupanumxor herdiceallousmorial to as refined Section the Cupertino Municipal Code,.Chapter 9.12.and IM Health and Safety .ak.QYus 255)2(x)?;_AN. All roofs shall be inspected prior to any roofing material being installed. Will Ne applicant or(wore building occupant sou cyvipment or dews=which If a roof is installed without first obtaining an inspection,I agree to remove crit hazardous air coneminan as defined by the Bay Area Air Quality Management all new materials for inspection. DistriC17 ❑Yes No I have mad the hva anus materials requirements under Clepmer 6.95 of Om Califor ria Hca W&Safmy Cade,Sections 25505.25533 and 25536.1 undersand thatifthe Wilding docs not currently bre itc e tht u is my mspovihility,to notify the acupant of the requirements wldmnm hnanlp➢orm iveanem or Certirimatt of Occupen . Signature of Applicant Date Owner ser authorivcd.,Cr( All roof coverings to be Class"B"or better Daa CITY OF CUPERTINO I 1 of 1 PERMIT RECEIPT OPERATOR: kiersaw COPY # 2 Sec: Twp: Rng: Sub: Elk: Lot: APN . . . . . . . . : 36206007.00 DATE ISSUED. . . . . . . : 07/29/2005 , RECEIPT #. . . . . . . . . : 30574 REFERENCE ID # . . . : 05070200 SITE ADDRESS . . . . . : 1105 ELMSFORD DR SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : CATE THOMAS M AND EDNA P ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4908 RECEIVED FROM . . . . : HUSSEY BROS. INC. CONTRACTOR . . . . . . . : HUSSEY, STEVE LIC # 20758 COMPANY . . . . . . . . . . : HUSSEY BROS INC ADDRESS . . . . . . . . . . : 640 TAYLOR AVE CITY/STATE/ZIP . . . : SUNNYVALE, CA 94065 TELEPHONE . . . . . . . . : (408) 733-6360 • FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL BPERMFEE VALUATION 7, 600.00 147.96 0.00 147.96 0.00 BREMAIRHAN NO.UNITS 1.00 10.26 0.00 10.26 0.00 BENERGY PERMIT FEE 147.96 71,.02 0.00 71.02 0.00 BREMFURN NO UNIT 1.00 14 .31 0.00 14 .31 0.00 PPERMITFEE FLAT RATE 1. 00 38.37 0.00 38.37 0.00 BSEISMICRE VALUATION 8, 000.00 0.80 0.00 0.80 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 359.46 0.00 359.46 0.00 METHOD OF PAYMENT AMOUNT NUMBER _________________ ____________ __________________ CHECK 359.46 24838 TOTAL RECEIPT 359.46 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 '+ 10300 Torre Avenue 140, J Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fac(408)777-3333 ®UPEkTINO Building De artment JOB ADDRESS: IIbs 1111S P 0 r- PERMIT 7f�2ov OWNER'S NAME: t"e, caff PHONE # GENERAL CONTRACTOR: v & FAX # Yi d 7D t-s-i49 n 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 Elec 'cal Excava 'on Fencing Flooring: CarKting Linoleum/ Woo Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractignature Date 09DIODC O among, CITY OF CUPERTINO FURNACE/AC *CUPERTINO PERMIT APPLICATION FORM APN # Date: ,3Coa- cam- �� Building Address: r NOS- CIV.,"34t7 0r- Owner's Name: /k 0 0 I c q9/ph e . � — :)969 Q O q License Contractor: a ( Li #-:I iO �wsse ros. � 7.S-G6 Contactm- 1 1 VSSQ Cupertino Business License #: Building Permit Info: Bldg ❑ Elect Plumb Mech Job Description: nn I'eP k 0 Residential Commercial ❑ For Residentialns llations: Attic ❑ ls` floor 2"d floor❑ Adhere to min set back requirement E] For Commercial Installations: Replacement same weight ❑ Additional weight (structural calcs) ❑ Structural Calculations required for new installation ❑ New installation Planning Approval Re uired ❑ Cost of Project:7&0i Type of Construction: Occupancy group: Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area: New Location ❑ Replacement Qty. if Applicable Fee ID Fee Description Fee Group BENERGY Energy BUILDING BREMFURN Furnace MECHANICAL BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10, 000 cfim 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