08010040 I' CITY OF CUPERTWO -;.� «x�. � '%sem '� x �'�``i`�'
BUILOING'DIVISION• PERMIT.- €CQNTRACTQR�INk'QIiMATIQN` "
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PERMIT NO.
BUILDB.Q/sA�RESsW ESTATES DR SANDIUM � 08010040
OW NEWSVN2ASME7: PERMIT L4UE DATE
PETER PALUZZI 4223 VERDIGRIS CIR 01/07/2008
lip Eo SANITARY NO. CONTROL NO.
(408) 894-9072
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
p0 LICENSED CONTRACTOR'S DECLARATION W am Ib Description
1 hereby affirm t 1 li¢nunm
d under provisions of Carter 9(eomueinOlp
g
p� with Section 741011)of Division 3 of the Business arnit Professions Code.and my Imams is FURNACE REPLACEMENT
s in full none and of
i0: in all r Clan Caroni
aro
�F� Dam Contranar
ARCHITECTS DECLARA O(
i�i lundcrsund my planscallonuudas public records
0
4m
H Licensed Professional
OWNER-BUILDER DECLARATION
I hereby etrvm that I am exempt from the Contractors Livens Law for ton
C o following mason.(Salon 7031.5,Business and Professions Cale:Any city or county
f$ which requires a permit to...swa,alar.improv,.demolish,or repair any strum
-i< prior to its issuance,also requires the applicant for such Permit o El,a signed statement
gothatWislicensed pursuan'trothe provisions ofineConnector's lianasaw(Capmr9 Sq.F[. Floor Area Valuation
(commencing with sccuon7000)ofDivision 3ofImBusiness and Professions Code)ar $2381
that he Is exempt themftom and the basis for the alleged exemption.Any vlolat an of
section 7031.5 by any applicant for a permit subjects W applicant m.civil penally ofNumber Occupancy Type
not coma than five hundred dollars(x000). 3 6 9 2 3 0 41AN
0 1,as owner of but,property.Or my employm with wages m thick sole compensation,
will do the work,and the structure is rut intended or offered for sak(sse.70a4,Business Required Inspections
and Pmfacd.r.Code:The Contractor's Liana es law doret apply man owner of " q p
property who buildsorimpmvvth orm,andwnn doessuchwork himselfortioni his
own employees,provided thauuch improvements are not intend uraReredfmailelL
however,W building or impmvemeni la sold within om year of compledon.W owmr-
builder will have the Written of proving that he did not build or improve for purpose of
sak.).
1.as owner of the i mpeny,am=elusively contracting with licensed contractom as
construct W project(Sec.7064.Business and Prof=sioas Code:)The Camtractafs U.
can.law do=out apply as an owner of plopeny who builds err Improves W..and
who contracts forsuch pmjocs with a convanor(s)licensed purment as that ComractMa
License Law.
0 lam=annotmder See .BAPCfurWmasmn
Owner Da¢
WORKERS COMPENSATION DECLARATION -
1 thereby affirm under penalty of perjury cone of the following declarubns
ave and will maintain a Ce tifiemm of Conant to self-insum for WorloYSCompen-
to provided far by section 3700 of W abm Code,for the Performance of the
work for which this permit is issued.
0 1 have and will maintain Worlices Compensation Imeana,as required by Section
3700 of the Labor Code,far dm performance of the work for which this permit is issued.
My Workers Compensation lnmrmce carrier and Poliry,
numbr
Carrier 'f(QprMPolicyNo.: 1^ w(•l Z
CEwAOION yC—
FROM WORKERS'
COMPENSATION INSURANCE
(ITU scrim need action emn,lemd if the P,rmiUs forms,handreddallars($100)
or Ims.)
1,miry Nat in the performance of the work for which this Permit is satud,I shall not
employ any person in any mansmrso an an become subject in ton Workcn'Compemafirm -
Laws of Califomia.Data
Applicant
NOTICE TO APPLICANT:IL after making this CeniEcate of Exemption,you ahauld
become subject to the Workers Compensation provisions of tin LAW,Cade.No most
,J z forthwith comply with such provisions or this permit shall he deemed revoked.
Z ^ CONSTRUCTION LENDING AGENCY
(—ice Ihereby affirm that there is a construction lending agency for the perfwmamx of
CG 7 tin work for which this permit is issued(Sec.3097.Co.C.)
Qlender's Name
7 z Lenders Address
U O 1 unify that I have read this application and state that the above information is
U, f"' comm I agree to comply with all city and county ordinances and sure laws mining to
0U building construction,and hereby authorise mprwmtnivcs or this city to enter upon ton
,r is-I above-memened property for impection purposes.
F L1. (We)agree Ire save,indemnity and keep harmless me City of Capcnina against
fn Iiabilitics.hogmens,coss and carcasses which may In any way acme agai=r said City
A consequence of the RSTA 6 of his D WILL
U Z APPLICA UNDERSTANDS i D WILL COMPLY WITH ALL NON-POINT Issued by: Date CY.
SOURC ULATIO
T. �Z Ac��kL
MAA . 1-7`1-7 W Re-roofs
Signatum a Pplrc HAZARDOUS MATERIALS DISCLOSURE DataType of Roof
Will the applicant or future building Occupant store or handle boxem ore material
as defined by the Caparison Municipal Cade.Chapter 9.13.and the Health aM Safety
Code.secaonz553x(.)+ All roofs shall be inspected prior to any roofing material being installed.
❑Yn
Wal the applicant of future building occupant use equipment err device.which If a roof is installed without first obtaining an inspection,l agree to remove
thmartlnus aircimuminors at acOnca by the Bay Area Air Quality Management all new materials for inspection.
tdcs7 r
0Y= Nu
I have mad dm thmrdms mamrials requifcmcr s umkr Chapter6.95 ofthe Califor.
nice Health&Safcty Cade,Secuon,M505,25533 ani[understand Wt if dm building
docs urmntI h,c a moan,Net It is my r=pamibility m mdfy dm oaupant of d e
m t mawhieh math epriormiss coof,C,ourta rOcaapaney Signature of Applicant Date
Owner on atrtnnd.<a agent m I All roof coverings to be Class "B"or better
CITY OF CUPERTINO
• 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36923041. 00
DATE ISSUED. . . . . . . : 01/07/2008
RECEIPT #. . . . . . . . . : BS000003638
REFERENCE ID # . . . : 08010040
SITE ADDRESS . . . . . : 10865 W ESTATES DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : PETER PALUZZI
ADDRESS . . . . . . . . . . : 10865 W ESTATES DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4537
RECEIVED FROM . . . . : YIU-HANG LEE
CONTRACTOR . . . . . . . : MICHAEL LEE LIC # 28867
COMPANY . . . . . . . . . . : SANDIUM
ADDRESS . . . . . . . . . . : 4223 VERDIGRIS CIR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95134
TELEPHONE . . . . . . . . : (408) 894-9072
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 2, 381. 00 0 .50 0. 00 0. 50 0. 00
1MPERMITFE FLAT RATE 1. 00 40 .79 0. 00 40.79 0. 00
1MRRAA UNITS 1. 00 61.19 0. 00 61 .19 0. 00
1PPERMITFE FLAT RATE 1 . 00 40.79 0. 00 40 .79 0. 00
1TRAVDOC FLAT RATE 1. 00 40.79 0. 00 40 .79 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 184 . 06 0. 00 184 . 06 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
-----------------
CREDIT CARD 184 . 06 VISA
--------------- -- .. ,
TOTAL RECEIPT 184 . 06
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
---- --------------------------- -------- ---- -----------------
113 SLAB 301 ROUGH PLUMBING
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL 506 GAS TEST
507 FINAL PLUMBING 508 FINAL MECHANICAL
•
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' CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN# (0q
2 :3 C If I , o O Date:
O
Building Address:
Owner's Name: Phone#:
ale tev, f z�d- u--b- 4A 84�) t730
Contractor:�y�� Phone#: 07 Z-
"w"�` Fax #: (,Go 604 a50J
Contractor License#: Cupertino Business License#:
a 91G- 7
Contact: Phone #:
Fax H.
Building Permit Info:
Elect Er� Plumb Mech
Residential Commercial ❑
Job Description:
For Residential Installations:
Attic ❑ I" floor 2"d floor ❑
Adhere to minimum setback requirement ❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural talcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction (Usage Class):
`- 23g I IZZE/L
Strapped ❑ On Platform ❑ Bonded New Location ❑ Replacement
Valuation:
Green Building: Must attach Green Building Check list to this application
CITY OF CUPERTINO
���� FURNACE/AC
•CUPERTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
FURNACE FURN/AC
1MCRAA Connnercial-Repair/Alteration/Add to M
ea heating appliance,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 appliance,refrigeration
unit,cooling unit,VAV boxes,
absorption unit or ea heathing, cooling
absorption,or evaporative cooling sys,
incl install of controls regulated by
this code.
lei 1MCSUSHTR Commercial Install/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted unit heater.
IPGASCOM Commerical for ea gas piping System P
1-4 outlets
I BPGAS For each gas piping system of 5 or P
more per outlet.
1MCAPPVNT Commercial for the install/relocate/ or M
replacement of ea appliance vent
installed ¬ incl in an appliance
permit.
1BSEISMICO Commercial Seismic B
IMRRAA Residential Repair/Alteration/Add to M
ea heating appliance,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,absorption or
evaporative cooling system,incl
installation of controls regulated by
this code.
1MRSUSHTR Residential Install/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted unit heater.
1MRAPPVNT Residential for the install/relocate/or M
replacement of ea appliance vent
install ¬ incl in an appl permit.
CITY OF CUPERTINO
FURNACE/AC
CITY OF
•CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
FURNACE FURN/AC
-1PGASRES -Residenti5l-for ea gas piping system of- P
1-4 Outlets
1BPGAS For each gas piping system of 5 or P
more per outlet.
p 1BSEISMICR Residential Seismic B
1MECPLNCK Mechanical Plan Check M
]MFR=<100 Furnace Syst<=100k BTU install or M
relocate ea forced-air/gravity type
fumace/bumer, incl ducts/vents
attached to such appliance up to and
include 100,000 Btu/h
1MFRN>100 Furnace Syst>100k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance over
100,000 Btu/h
/ 1 EPERMITFEE Electric Permit Fee E
r 1MPERMITFEE Mechanical Permit Fee M
1PPERMITFEE Plumbing Permit P
1TRAVDOC Travel Documentation B
1BUSLIC Business License B
•
CITY OF CUPERTINO
FURNACE/AC
CITY OF
CUPERTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
AIR FURN/AC
CONDITIONING
— ---
IBCAlI2I-IAN Commercial A/CUnits<= l Ok CFM B
1MCRAA Commercial Mech Repair/alt/add M
1BSEISMICO Seismic Commercial B
1PGASCOM Commerical for ea gas piping System P
1-4 outlets
1PGASRES Residential for ea gas piping system P
of 1-4 Outlets
IBPGAS For each gas piping system of 5 or P
more per outlet. Comm/Resid
1BREMAIRHAN Residential A/C units <= I Ok CFM B
IMRRAA Residential Mech Repair/alt/add M
IBSEISMICR Seismic Residential B
IEPERMITFEE Electric Permit E
IMPERMITFEE Mechanical Permit M
IPPERMITFEE Plumbing Permit P
1TRAVD0C Travel Documentation B
IBUSLIC Business License B
i
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
0
BuildingDe autment
B ADDRESS:
JO : PERMIT #
0$65 t f�-�� o l o 040
OWNER'S NAME: PHONE # Z
GENERAL CONTRACTOR FAX # So
I am not using any subcontractors: � ,4 . Z ddA , l 7 0
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
caner/Contractor Si ture Date