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03090035 CITY OF CUPERTINO - BUILDING DIVISION PERMIT CONT Ue"TORANFORMATION ' s .ai x��,. M,Y_�.Akh"•,�.xL 'rte* L+> '2d eua roy-. BUILDING ADDRESS: PERMIT NO. 03090035 R' AME: PERMIT ISSUE DATE PHONE: SANITARY CONTROL NO. ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH +op LICENSED CONTRACTOR'S DECLARATION O O O O r= 1 thereby from that I am licensed under provisions of Chapter 9(commencing Job Description W ith0Pmfcasions Code,and my license is ��® .O of Vision! N ;'q_ S / AIR CONDITIONER REPLACEMENTGSEP 0�5 2003 A CICU 1 understand my plans shall W used as ublm record. o t, Liecnud Pr resammil 1B1aT� S OWNER-BUILDER DECLARATION Y��®Ip'A� <2 1 hereby affirm that 1 am exempt from doe Contractor's License Law for the BUILDING p 0 following mason.(Section 7031.5.Business and Protestants Code:Any city or county <$ which requires a permit to construct,alms.improve.demolish,or repair any structure poor to its issuance.also requires the applicant for such permit to file a signed suwment csp that he is licensed pursuant to the mvisiotu(if the ContanLaw Sq.FL Floor Area Valuaton et- (commencing with Section 70N))of Division 3 of the Business and progressions Csxm)or i Nat ha is exempt therefrom and the basis for the alleged exemption.Any violation or Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty or APN Number OType not mom Our five hundred dollar,($500). - - - - ' Occupancy y 0 h as owner of the pmpcny,or my employees with wages az their sole compensation, will do the work,and the someone is not immnded or offered for sale 7040.Business 204 - UNDERF Q( d$ HVt,+ �T�+� and Professions Codc:The Coommun's Liceuc law dors not apply m an owner of ns pmpeny who builds or improves Neuron,and who does such work himselfor through his 301 - ROUGH PLUMBING own employees,provided mat such improvements are not mmndee cro0ared for sale.If. 3O3 - ROUGH MECHANICAL h.cvep the building or improvement is sold within one year of completion,the owner- builder will have me burden Of proving Nat he did not build or improve for purpose of 3 04 - ROUGH ELECTRICAL sale.). 0 1.as Owner of the propertyam exclusively contracting with licensed contractions to 505 - FINAL ELECTRICAL cotutmct the pmjecl(Sec.7044.Business and Professions Code:)The contractor,Li. 507 - FINAL PLUMBING cease law does not apply 0 an owner of property who Wiids or improves daemon,and who comracta for such projects with a cornmemos)licensed pursuant to the Comvanon' 508 - FINAL MECHANICAL L.e1 son Law, 514 - FINAL PUBLIC WORKS ❑Ivo acmpt under See ,B&PCfor this rtason 1pr Data WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following doelarations: 0 I haw and will maintain a Certificate Of CrmmM m self-insure for Workeri Compton ration,as pmvided for by Section 37W of the labor Code,for the p mformanee of the work for which this permit is issued. 0 1 have and will maintain Worker's Compensation Insurance.as required by Section 37W of the labor Code.for No performance of the work for which dais permit is issued. My Worker's Compensation Insurancerartie1 and Policy num her am: c A✓G7CEPIO WO CERTIFICATE OF EXEMPTION WORKERS' COMPENSATION INSURANCE Mix section need not W completed if the pernh is far one hundred dollars(5106) or Less.) 1 certify mat in the performance of the work for which this permit is issued.l shall not employ any person in any manna sr,u m Wcome subject to the Workeri Compensation Law.of California.Data Applicant NOTICE TO APPLICANT:If,after making this Cernfieam of Exemption,you should become subject to NO Workers CoMIChou loo provisions of me Lalmr Cade,you mus D fonhwilh comply with such provisions or this perm i t shall W deemed revoked. ZO CONSTRUCTION LENDING AGENCY I hereby affirm Nat mere is a construction lending agency fur me performance of Y the work for which this permit is issued(Sec.3W7,Civ.C.) l2 Lender's Name 3. Lcndeis Address Z) z ;)C) 1 c icy mat I have read this application and show LOU No about information is J. Pcoma.I agree to comply with all city and county ordinances and sum laws totaling to �T) building construction.and hereby authorise tepremnutima of this city to enter upon me, aWve-mentioned mmrly for impaction purposes. ry (We) rte t save.indemnify and keep harmless No City of Cupertino against N liabilities dgmentsl costs and a gramos which may in any way accrue against said City J in eon wen f NJ granting of this permit. (x� ^ APP CA UND RSTANDS AND WILL COMPLY WITH ALL NON-P NT Issued by:S � Date SO C E L ONS. C/ Re-roofs S' ofA icanUContracmr Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building Occupant sham or ban dle hazardous material az de by the CuMnino Municipal Code.Chapter 9.12,and the Health and Safety Section 2ssu(an All roofs shall be inspected prior to.any roofing material being installed. 0Y. Will me a"licam o fmure building occupant use<qui If a roof is installed without firs[obtaining an inspection,I agree to remove nmem or devices wham g P emit hamming,air contaminants az dcfned by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes t 'IU Ihx �l the hazardous materials requirements under Chapter 6.95 ofthe Califory nix He.1 Safciy Cod.Sections 25505.25533 and 5534.1 undersand that ifthe Wilding does vrmnll'haw a tenant that it u my msponsihilioy m notify the arca o of c on emu w,ch must c mm poor to issuance Of a Certificate of Occup y�� ej Y 313 Signature of Applicant Date Ow crorammonite agent Date All roof coverings to be Class "B"or better CITY OF CUPERTINO em 1 of 1 PERMIT RECEIPT OPERATOR: suem COPY # 1 Sec: Twp: Rug: Sub: Blk: Lot: APN . . . . . . . . : 37537066.00 DATE ISSUED. . . . . . . : 09/04/2003 RECEIPT #. . . . . . . . . : 23023 REFERENCE ID # . . . : 03090035 SITE ADDRESS . . . . . : 10709 JOHANSEN SUBDIVISION . . . . . . . CITY . . . . . : . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : DENNIS GILL ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : LANCE EASTMAN CONTRACTOR . . . . . . . : LIC # COMPANY . . . . . . . . . . : ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . . , . TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL __________ _____________ __________ __________ __________ __________ __________ BREMAIRHAN NO.UNITS 1.00 9.50 0.00 9.50 0.00 BREMRECEPT NO. OUTLETS 1.00 1.11 0.00 1.11 0.00 BENERGY PERMIT FEE 1.00 23.10 0.00 23.10 0.00 BSEISMICRE VALUATION 9, 000.00 0.90 0.00 0.90 0.00 PPERMITFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00 EPERMITFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00 MPERMITFEE FLAT RATE 1.00 35.52 0.00 35.52 0. 00 __________ __________ ---------- TOTAL PERMIT 141.17 0.00 141.17 0.00 METHOD OF PAYMENT AMOUNT NUMBER _________________ ------------ _--__------------- OTHER 141.17 MASTERCARD TOTAL RECEIPT 141.17 VOICE ID DESCRIPTION VOICE ID DESCRIPTION 204 UNDERFLOOR FRAME 301 ROUGH PLUMBING 303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL 514 FINAL PUBLIC WORKS CITY OF CUPERTINO FURNACE/AC �CUPER,TINO PERMIT APPLICATION FORM APN# Building Addre s: / b (� �I �0�7�►t)S'�7J Owner's Name: Phone#: IJ tS 40I3 Contractor: Phone: License#: nJ[�- Contact: (' s-0 Phone: Cupertino Business License#: to-)L)C45� r7S Y Building Permit Info: Bldg Elect ❑ Plumb ❑ Mech Job D cription: I NSTylu(- c,,u OF A i l Ccwt�+vt�rlL Residential Commercial ❑ For Residential Installations: Attic ❑ 151 floor ❑ 2nd floor❑ Adhere to min set back requirement❑ For Commercial Installations: Replacement sam"eight ❑ Additional weight (structural calcs) ❑ - Structural Calculations requued fo ew installation El New installation PlanningA rov Re uired ❑ / Cost of Pr ject: Type of Construction Occup group�/J 0-MV r y F / Strapped atform ❑ Bonded ❑ Sq.Ft. Floo a: New Location ❑ Replace t Qty. if ApplicFee 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 AhMPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPLANCHK Plan Check Fee BUILDING BUSLIC Business License BUILDING