06090002 CITY OF CUPERTINO
1S'A 4 Y`
BUILDING DIVISION PERMIT �C,OIVTRA ,.T.O',R;TN '�ZMATIN�,�;",
$n„ : •+3 rs
BUILDINGADDRESS: J AIR CONDITIONING PERMIT"°'06090002
11054 LA PALOMA DR
OW NER'S NAME: PERMIT SUE DATE
Ah LATSHAW GARY AND SUSAN 917 QUERCUS CT. 09/01/2006
14 NE: SANITARY NO. CONTROL NO.
(408) 655-0491
ARCHIIECf/ENGINEER: BUILDING PERMIT INTO,
BLDG O PLO MEOCH
loo LICENSED CONTRACTOR'S DECLARATION
Job D0SCi5ptlOn
uV+ I hmeby affirm that I am licensed under provisions of Chapter 9(commencing
mwith Section of Division 3 of the Business and Pnrofessions Code.and my liecom is REPLACE FURNACE
w in full fame,endo T(x64 t o
1 Z Lke cas N. Lk.N
Conuactar
££ RCHI'IECFS DECLARATION
C-a 1 understand my plana shall he used As public records
u.syU
• 1 Licensed Pmfcssienal
1005 OWNER-BUILDER DECLARATION
i I 1 hereby.niece that I I.J. umps from the Cssmms C a e:My taw far the
:00 (allowing rsama.(Section 7(01. Business and Improve.
cssiuN Code:Any dIY N cemny $2200
$w whkh require a e.permitAim hi cnm,the der,impmsu demWkh.Or mash ed structure
?i�, prior bits isswrc p Ymrtan din lheappin of for mchpermit tofause Lte atlauumem Valuation
Nella,isabngwdpursu.n7000)of Division
of othe f she
loons Cru(Chapter Sq.Ft.Floor Area
that W ndne pt Sec from and h basis In l of lie Budneeand Profeson.Any
Code)of
$ that Section
k exempt therefrom and de basis for the alleged essmant W Any vloladon O(
not mo dentin by Any and dolga for a permit subjects the,Applicant to a dull penally of y Occupancy Type
not mart dun fin hundred dollars(5300),
I,u owner of the popery.er my employm wins warn u their sok campcnsadan,
will clothe work,and die ahuctum is sol AesldedwaRered forvk(Sa.70e.Business ns Required Inspections
and Pfurcat ons Cade:The Contractor's LIcaNe law dao tot apply u An owner of q P
property who builds or improve demon,and who des ouch work himself Or through his
own employees,provided that such Impmwm M art wtinended MafTemd formh,if.
however.the building or Improvement is mid within ane year o(completion.the Owner-
builder will haw de burden of proving that he did ant build or Improve for purpose of
sok.).
O I,As Owner of the property,am ecluaiwly cOneaing with licensed moumwrs to
coNtrect the prom(Sec.7014,Business and Pro(esimu Code:)The Contractors Li-
cense LAW clan not apply 0 An owner of property who build.or improwa Merton,sad.
who contracts for such pmjeau what a contraer(s)licensed purmant to tie Centimeters
License law.
❑I Am..of undo Sec .B k P C far this mason
Owner Dae
WORKER'S COMPENSATION DECLARATION
I hcmby affirm under peNlly of perjury ole of ate following decland ons:
❑I haw And Will maintain aCenifeemof Commat to mlbinsum far Wadmrs Connum-
sNon,As,provided for by Satin.3700 of the Labor Code,far the performance of the
work for which thB Permit is issued.
0 1 haw and will maintain Workers Compensation Insurance,As required by section
3700 of the tabor Code,far the performance of ate work for which this permit is issued.
My Workers COmpensadan Insurance earner and Policy nu c am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ndsxetlnnnee1m, Compked i(dupMerkisforoNhundmddoBamlSt00)
or less)
1 cenifv that in the,perfo An a the waA for which Nis permit Is umunl I shYl ant
employ any porton in my AaQnma 'ect to the Worknn'Compcmaon
Laws of California.Due
Applicant
NOTICE TO APPUCAof.IL afar making this Ccri finis of Exilimption,No should
become vubJm to the Workers Compensation provisions of the labor Cade you mute
Oforthwith comply with such provisions or this permit Nall be dcemed rtwk¢d.
Zgyne., CONSTRUCTION LENDING AGENCY
F-t Ihereby affirm that then Is conswction lending agency for the Performance of
a the work for which this permit Is issued(Sec.3097,Civ.C.) `
W Q Lender's Nitnc
]z Lender's Address •'
U I certify that I have mad this application and sum that the show Information Is
Ey' correct.I agree to comply with all city and county eminences and stale laws relating to
O U building construction,and hereby authority mpmacnutiws of Nis city to four upon the
4A .hove,-mcmidgm property fariepctien Mripawhich m.
H 01 (We,)agree to saw,indcmmfy and keep harmless the City of Cupertino against
rq liebllitie,Judrmcnts.ceu andexpensn which may in any a'+Y serve,against said City
L)Z in consequence of the Swung of this permit
'•” AP ICA STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by; Date
S U E GUL NS.
.� Re-roofs
S,gn/yd pDl eaHAZARDOUS MATERIALS DISCLOSURE Type of Roof
/ Wlll the applicant ar future,building aecupml Yam orhandlc hmardow m.urid
as defined by ate Cupertino Municipal . aper 9.12.and de Halthand Safety
Code.Seed..2553200 All roofs shall be inspected prior to any roofing material being installed.
❑Ye No
If a roof is installed without first obtaining an inspection,I agree to remove
WIII the Applicant or future building attvpanl tee equipment or devices Which
Craft hA/.ardnw.11 a m=ienumclefinedd Bay Arca Air Quality Management all new materials for inspection.
DistricL7
• ❑Yea
I have read the hwamousmaterlelsrequimments under Chapur6.95 of the Califon
ole Hcalf�Safep ..'N=25505,25533Y 25534.lun(lc,mdthatifft WildinS
dace I cu ren+y Ia., era ,that It u my repamihility to nadry de mcupmt of Ne
ratioman ew t, r riwmissuaneao(acenif kar Occupancy' Sign re of Applicant Date
- P All roof coverings to be Class 'B"or better
Owner ter a acd a em Dam
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
•CUPEkTINO
Building Department
Jos ADDRESS: PERMrr#
P440`ii sq-
070 'Z--
OWNER'SNAME: 64eY (A 4rAL. PHONE # 665-04g
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: ►•c•� �' �/ -D(o
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
•
Owner/Contractor Signature Date
CITY OF CUPERTINO
em 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35616048 . 00
DATE ISSUED. . . . . . . : 09/01/2006
RECEIPT # . . . . . . . . . : 35869
REFERENCE ID # . . . : 06090002
SITE ADDRESS 11054 LA PALOMA DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : LATSHAW GARY AND SUSAN
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4718
RECEIVED FROM . . . . : JIM' S AIR CONDITION
CONTRACTOR . . . . . . . : JIM TURNER LIC # 25053
COMPANY . . . . . . . . . . : JIM' S AIR CONDITIONING
ADDRESS . . . . . . . . . . : 917 QUERCUS CT.
CITY/STATE/ZIP . . . : SUNNYVALE, CA 94086
TELEPHONE . . . . . . . . : (408) 655-0491
•FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
- - - - - ----- ------------- ---------- ---------- ---------- ---------- ----------
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
BSEISMICRE VALUATION 2, 200 . 00 0 . 50 0 . 00 0 . 50 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 164 . 78 0 . 00 164 . 78 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
---------------- - ------- ----- ------------------
CHECK 164 . 78 11662
TOTAL RECEIPT 164 . 78
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL
•
affi, CITY OF CUPERTINO FURNACE/AC
UPEkTINO PERMIT APPLICATION FORM
APN # Date:
3 -c� R-i - a
Building Address:
1/ S 64 L 6 wi
Owner's N e: Phone#:
Contractor: Phone: License#:
,—v's Ary COIJ 10ki Boa ss-0413 f 4G"16
Contact: Phone: Cupertino Business License#:
ZT w, —TU ✓1ve
Building Permit Info:
Bldg ❑ Elect CzJY Plumb C � Mech (�
Job Description:
Residential J?' U Commercial ❑
For Residential Installations:
Attic ❑ I" floor ❑ 2"d floor❑
Adhere to min set back requirement
or Commercial Installations:
eplacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required
Cost of Project: Type of Construction: Occuacygroup:
a ";L u-D a Z
Strapped ❑ On Platform 0 Bonded L1 Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
ApplicablQ Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cf n 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
/ PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BPGAS Gas Piping System Fee PLUMBING
BUSLIC Business License BUILDING