06090123 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS: A PERFECT CLIMATE `m"'06090123
22271 KENDLE ST
OWNER'S NAME: PERMIT ISSUE DATE
/ ` THOMAS MORTENSEN 10570 S DEANZA BLYD 09/15/2006
Ill E: SANITARY NO. CONTROL NO.
(408)86119545
ARCHITECTIENGINEER: BUILDING PERMIT INFO
!� O PLUMB
MECH
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ipp LICENSED CONTRACTOR'S DECLARATION Job Description
RF I hereby affirm that 1 am licensed under provisions of Chapter 9(mmmeocing
;Z`9 with Section 7001Ba(Dividon 3 ofthe Business and Prafestimu Code,and my[let.is
! N in ran forte and efrecL 3 g' ADD A�C
n Z
-no
Chea L'c.N
J pare •1 7 ca b Conbomber V 2
1p- ARCHITECTS DECLARATION
i$i I urnimsund my plans shall W used as public record,
ryU
a
4tt; Licensed Pmfessiansl
'y� OWNER-BUILDER DECLARATION
I hereby.(Sere that 1 1. exempt foto the contractor. :Any law for 0e
o o following moon.(Schon 7031-5,Business and prt,dem l Cade:Any m s county
i$
which requires n permit re eaes the,titer.hnpmsu,h permit
e m t i or each any uromcn, $9033
Pdormslimmunce,alwrol to am pmislotont fat cormanmttWecosete a gnedw¢mcm
�
that he laliccnsed pumunt to depmisionsmthe ConuacRr's Limns haw(Chapter 9 Sq. FI. Floor Area Valuation
i� (commencing with Section 700(1)of Division 3 of the Business sed Professions Cak)o
$ Net W u exemptNtmfrw
and de bolt forthealleged exempt ore My violation of
Section 7031-5 by any Applicant for a permit subjects use,applicant W a civil penalty Of p Occupancy •]Pe
.to.thio Bw hundred dollars($500).
❑1.u owner cruise Property or my employees with wags u their sola eompewtion. ..
will de dRwork.and the someone is notintemed oofrered Waste(Sec.7044.Bestrca Required Inspections
and Professions Cade:The Contractors Liana Law Ones ret apply W an owner of q P
property wW WIW ortmprow thereto.and who donsauchwork hW.&o through his
Own nexploycea,provided Out such improvements==I intended or offered forxxke If.
indictor.Ne Wilding
Wiburden
u improvement h sold within arc year of mmpkuw.Ne owe oflder will have the burdenof proving that W did rot dtiW m improve for purpose of
sale.).
❑1,as Owner or the pmpeny,am exclusively contracting with licensed mmacors an
monmtct the project(See.7044,Business and professions Cade:)The Cotmetors Li-
cense Law does mot apply an an owner of property who Wilds or impro ms thetoon.and
who cmtracu for such projects with a contractor(s)licensed pursuant W Ne Comaalor', '
Lice.Law.
❑1 am exempt under See .B&P C for this mann
Ownsr Date
WORKER'S COMPENSATION DECLARATION
I hereby arrive,under penally of perjury one of We following duclaradans:
Ms.and will maintain a CeniOcue of Consent in Rlfdnwrt for WorkeesCompcn-
don,as provided for by Section 3700 of the labor Code.for the pemmmmm or the
work for which Nin formula issued.
I have and will maintain Workers Compensation Insurance,u required by Schon
fl00 of NO Labor Cade,for too pe,farmance Of tha work forwhich this permit is Issued.
My Warkera rep/e o milia and Poliry number
tinier. /.� Gt' Policy No.: SYO(/�
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
fruit section treed not W completed UNe permit Is forone hundred dollars(SIM)
or less.)
I cenify that in the perratmance of to work for which this permit Is issued I,hall net
employ any person in my manner an as W become subject to the WorkerCompensation
Laws or California.Date
Applicant
NOTICE TO APPLICANT`.IL after making this CeOtOae of Exemption,you Mould
become subject W the Workers Compensation provisions of the Labor Code,you mot
.,Zforthwith comply with such provisions m this Permit shall W deemed mound
z O
,v CONSTRUCTION LENDING AGENCY
reel I herehy elflnn that Nem is a construction lending agency for the Performance of
a> the work for which this permit la issued(Sec.3(447.Civ,C.)
G; Lenders Name
7 Z lenders Address
V Q 1 comity that I have rod this application and man Nu the aWva InfomNan Is
L,F comm.l agree W comply with all city and county ordinances and some laws totaling W
0 U building construction.and hereby authorial mpraentattve,or this city to corer upon tee
W soave-mmnti...d property for inspection purposes.
(We)agree to one,indemnify and keep harmless the City or Cupertino against
,F•,fa'A
liabilities,judgments,cases and..K.which may in any way....,Austsald City
C.3 Z in canRgucrtee or the grand,of this Permit
�-+ by: Date
APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued ( —f x/ 3•.
SOUR ULATID
, de- - 9 •ice a Re-roofs
sig urrofA piicastAcou.cen, aW Type of Roof
HAZARDOUS MATERIALS DISCLOSURE
W3I1 Neapplianl or futum Wilding oectimt more or handle In ardoo matedal
as dented by the Cupertino Mu 'eipal Code.Chapter 9.13,and the Health and Safety
Cade.Section 255324)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yns No
If a roof is Installed without first obtaining an inspection,I agree to remove
Will the applicant Or future Wilding ocupam use equipment Or dcvim which
mit havudno air emumirun u de0md by Une Bay Amo Air Quality Mansgcmcnt all new materials for inspection.
D tr R
❑Ya No
I have read the harumrusrttaandabrequbcmcnu undbrChapierd950(t eCalifor.
ITh Health&Safmy Cede,Sec6ons25505.25533 sod 25534.IundentWd thmifthe Wilding
does ret urmndy have.want that it h my responsibility W ratify the acnvpant or the
aim uwhichm W t ar eniOcaanOf m Signature of Applicant Date
owner or.uu ari7nd agent ! Daan All robe coverings to be Class"B"or better
1
CITY OF CUPERTINO
om 1 of 3 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 32613105 . 00
DATE ISSUED. . . . . . . : 09/15/2006
RECEIPT # . . . . . . . . . : 36060
REFERENCE ID # . . . : 06090123
SITE ADDRESS . . . . . : 22271 KENDLE ST
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . :
OWNER . . . . . . . . . . . . : THOMAS MORTENSEN
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . :
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) 86119545
EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
- --------- - ----------- - ---------- ---------- --------- - ---------- ----------
BREMAIRHAN NO.UNITS 1 . 00 10 . 26 0 . 00 10 . 26 0 . 00
BREMRECEPT NO. OUTLETS 1 . 00 1 . 20 0 . 00 1 . 20 0 . 00
BENERGY PERMIT FEE 1 . 00 34 . 86 0 . 00 34 . 86 0 . 00
BSEISMICRE VALUATION 9, 033 . 00 1 . 00 0 . 00 1 . 00 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 162 .43 0 . 00 162 . 43 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ----------------------------
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL 508 FINAL MECHANICAL
•
Community Development
10300 Torre Avenue
-r/' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
46UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT #
as -) l e S+ 0 �rro 2-3
OWNER'S NAME: 71 o.rw ynor Y s ev► PHONE # &la l- 955Y s'
GENERAL CONTRACTOR a e, FAX # S_(o l -95V10
I am not using any subcontractors: .!/YYL
Signature rDate
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
tSheet
et Metal
• Rock
Owner/Contractor Signature Date
CITY OF CUPERTINO C�I2�j
W FURNACE/AC
OUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
Owner's Name: Phone #:
-Tknovy-NctsMrJfVev, y f5k • 9(0 O
Contractor� Phone: License#:
-Wec.� V,vvt e yob - P(ol-9SY � -� a3/sk
Contact: Phone: Cupertino Business License#:
1L', v, S S-y
Building Permit Info:
Bldg ❑ Elect 0--" Plumb Cly Mech
Job Description:
Auld Al(, A ovr Edi
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1' floor ❑ 2"d floor❑
Adhere to min set back re uirement
or Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation El
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: Ocpar}cy 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 cfm MECHANICAL
BREMRECEPT Recptl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOMSeismic Commercial BUILIDNG
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
BPGAS Gas Piping S stem Fee PLUMBING
BUSLIC Business License BUILDING