08080071 CITY OF CUPERTINO
BUILDING DIVISION PERMIT I�'COI�I,TRA ,R.INFOI.tMATION
BUILDING ADDRESS: PERMIT NO.
? 1 '1.26 ]A NDA VISTA DR CONDITIONED AIR 08080071
OWNER'S NAME: PERMrr ISSUE DATE
! SSRN JAMES M 1701 LITTLE ORCHARD ST 08/11/2008
NEN: (408) 291-2220 SANffARY NO. CONTROL NO.
ARCHITEC]ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
(� t9 C=
coca LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby sairm mIat 1 am licensed under previsions of Chapter 9(commencing p
with sccmnTaw)of0iviskn 3 of do,Business and Prekssloes tom.and my license i, RMV & REPLC FURNACE
In mu n rotes anefai
Vqi LicenmClan - Lk.M
9
qFqDate t Contractor Ol i M1i,
!�D ARCHITECTS DECLARATION
i W U
i understand my plans adult he used u public records
GI-, Licensed Pefessiorul
OWNER-BUILDER DECLARATION
I hominyalfrm Nat I am exempt from the cimusetars Lic'mat law far the
E 00 following mason.(Scemn 7031.5.Business and Prefztdov Cade:Any city m county
5$�i which requires u permit in consumer.alter.improve,mmolkh,or repilr any museum ,
i prior to its issuance,alar,mquires the applicant for such permit to File a signed statement
�< wtneisHennaedImumumtinth,provisionsofthec.nuxur'sU..law(Chatter9 Sq:Ft. Floor Area[ Valuation(commencing with Searle. N
)of Division 3ae Business and Prereuiov $7000 Cedc)or 7000
Q 3 dart he u exempt therefrom and the basis for the alleged!exemptiea Any violation of
Section 70]1.5 by airy applicant for a permit sebjttu the applicant to a civil penalty ofNumber Occas
nct mom man five hundred dollars(S5OB. 3 5 616 018 . Occupancy Type
❑I,u axmr of tee preperry.or mY eeployev wire wages u twiruk eempertaauon,
a,Business;
w Pmraftemmedon `c�Tam Coont�rs i�La doea`cat apply eT an a Required Inspections
property who wilds or ire pmwa dcrcon.and who does such work himulf or through his
ow.employes,puvided met such impmw:menu art not intended oreferod for tele.If,
however,the wilding or improvement is sold within one year of completion.the owner,
Wilder will have dm writes of proving Bret the did Mt wild or improve for purpose of
sale.).
0 1.as owner of the property am exclusively contracting with licensed mntractars in
costru t me project(Sc,.7044,Business ave Prof armorer Code:)The Con atemes U.
I.law does not apply a an owner of property who wilds or impvvas thereon,and,
who contracts for such projects with a eonbactor(s)licensed pursuant On the Canosi
Lt..taw.
O l am except under Sec .B k P C fm this won
Owner Dau
40WORKER'S COMPENSATION DECLARATION
1 hereby aurum under penally of perjury one of the fallowing declataumu:
1 ha,m and will maintain a Certificate of Covent in self-imam,for Workers Compere
smion,as provided for by Section 37W of the Mbar Code,for the pert annio ce of the
work for which this permit is issued.
0 1 base and will maintain Workers Compensation her rancc,an"Inved by Section
3700 Mme labor Code.for the pcdormanco of de wart for which this permit u toed
My waders ccmn;sati vutame carrier/and Poliry n bar are:
Carrier: ag Z7 _.)fPa ryNo.: 2Z0001
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Gos.eCHaa need Out be comptcted Ilme penult Is formic hundred defiant($IW)
or lett)
I cattily that in the performance of to work for which this permit u issued.l shall am '
employ any perm.in any mune,u as in hecom.ubjncl I.the Worked Compevatiom
L,wa of California-Dam
Applicant
NOTICE TO APPLICANT:If,after making this Ccnifresse of Exemption,you should -
beceme subject in the Workers Compensation previsions of me labor Cad,you mute
0 forthwith comply wit such previsions or this perinit,hall he deemed noted.
'z r. CONSTRUCTION LENDING AGENCY
[—t I hereby afire this then iso construction lending agency for to performanceOf
R'
the work for which Bus permit u bound(Sce.3097,Civ.C.)
WA Lenders Name
�
7 2 Lenders Add.
U C 1 unify mat I have mad this application mat sur,this tie above information u
IL,E Ordinanceandrt
nSL 1 agree In comply with all city and county Ordinances a ,tate tam kdag to
0 L�-,! wilding construction,and hereby mutation rtpreseautiw of mu city to enter upon the
fy save-menuoned propertytet for Inspection purposes
(~ G (we)agme to masse,indemnify and keep bnnlm the City of Cul,me.agilvt
IV!Z in
Of theamuuld cxperueswhich may in uY waYurneagilvt mid Ciq
U z A APPLICANT
of the UNDERSTANDS
of mu permit.
r APPLICANT UNDERSTANDS AND WI OMPLY WITH ALL NON-POINT Issued by: Date cV—I--•--/
SOURCE¢t�GULA NS. //
Stgm
nu fApplicanUCendacmr Dam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Willthe applicantmform III aceupaptrmreor haMlc Histim anmasetkl
u defined io tee Cupertino Municipal Cade.Chapter 9.13.end the HW m and Safety
Code.Section zss3zU)7 All roofs shall be inspected prior to any roofing material being installed.
❑res ,e[Nu
Win the, licant.1 metre Wilding ocu t use If a roof is installed without first obtaining an inspection,I agree to remove
Trp g pan equi it Qu or devise which g Pe
..it haraNnus air conumivnu u MFined by the Bay Area Air Quality Management all new materials for inspection.
District]
DYca YnVo
I have read the Wondow mamriatsmquimmenu under Chapmr6.95 of the Califon-
nkHcalN&Sofsty Code.Sceriov 25XL5,ZSSl]uld 25534.1 urgs7xsmW thmifdm wilding
does ret cumendy have a mnanl mat it u MY re,poW bility to notify the oceupsnt of the
regmrem, hkh ustlmmm riorelasr, era Ccrtimateofacupermy. Signature of Applicant Date
Owner or uthe cd agent Dam All roof coverings to be Class npaa or better
CITY OF CUPERTINO
• 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35616018 . 00
DATE ISSUED. . . . . . . : 08/11/2008
RECEIPT # . . . . . . . . . : B5000005742
REFERENCE ID # . . . : 08080071
SITE ADDRESS . . . . . : 11126 LINDA VISTA DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : NISSEN JAMES M
ADDRESS . . . . . . . . . . : 11126 LINDA VISTA DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4770
RECEIVED FROM . . . . : CONDITIONED AIR
CONTRACTOR . . . . . . . : RICHARD READ LIC # 22334
COMPANY . . . . . . . . . . : CONDITIONED AIR
ADDRESS . . . . . . . . . . : 1701 LITTLE ORCHARD ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408) 291-2220
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- -- -- ---------- ---------- ----------
13SEISMICR VALUATION 7 , 000 . 00 ' 0 :70 0 . 00 0 . 70 0 . 00
].EPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 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
7.TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
----- --------- ---------- ----------
TOTAL PERMIT 225 . 05 0 . 00 225 . 05 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 225 . 05 VISA
---------------
TO'T'AL, RECEIPT 225 . 05
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- - ------------------- -------- ----------------------------
505
-----------------------
505 FINAL ELECTRICAL 507 FINAL 'PLUMBING
508 FINAL MECHANICAL
CITY OF CUPERTINO
FURNACE/AC
• CUPEkTINO . PERMIT APPLICATION FORM
APN # c Date:
-36 cooio , oD g - II - g
Building Address:
ZG L -vr) flr .
Owner's Name: Phone#:
ry\ Cg0,6) -+In _ -Ll O
Contractor:
Phone#: Z41 �iZ-Z C7
Ca, 6,\
-\-\ C' `AZ i` n-b O Fax #: ZZ C(
Contractor License#: Cupertino Business License#:
Contact: Phone#:
-0 r"-\-
�J ci,r�-tv� Z C'12 r'C` ✓� Fax #:
Building Permit Info:
Elect Plumb ❑ Mech
Job Description: (�
�mO Cie 1 r�(»�cCP V YNZ C e
Residential Commercial
For Residential Installations:
Attic ❑ I" floor ❑ 2nd floor ❑
Adhere to minimum setback re uirement ❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction (Usage Class):
t OOO
Strapped On Platform Bonded New Location Replacement
Valuation:
Green Building: Must attach Green Building Checklist to this application
Community Development
10300 Torre Avenue
1?j Cupertino CA 95014
c Telephone(408)777-3228
CITY OF Fax(408)777-3333
OCUPERTINO
Bujillding DLartment
JOB ADDRESS:OWNER'S NAME: ��m N1vYr _GENERAL CONTRACTOR L 1• Z'L u
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followin 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/ Wallpa
Paving
Plastering
Plumbing
Roofing
Septi , -ank
S t Metal
Sheet Rock
Tile
er/C frac or Si ature Date
CITY OF CUPERTINO
Sul
FURNACE/AC
• CUPEkTINO FEE SCHEDULE
AIR CONDITIONER:
Qty. if
A licable Fee ID Fee Description Fee Group Permit Type
BCAIRHAN Commercial A/C Units <= l Ok CFM B FURN/AC
MCRAA Commercial Mech Repair/alt/add M
SEISMICOM Seismic Commercial B
BREMAIRHAN Residential A/C units<= 10k CFM B
MRRAA Residential Mech Repair/alt/add M
BSEISMICRE Seismic Residential B
EPERMITFEE Electric Permit E
MPERMITFEE Mechanical Permit M
PPERMITFEE Plumbing Permit P
BREMRECEPT Electric Receptacles E
PGASCOM New Gas Piping System Commercial P
1-4 Outlets
PGASRES New Gas Piping System Residential P
1-4 Outlets
BPGAS Gas Piping System 5+ Per Outlet P
TRAVDOC Travel Documentation B
BUSLIC Business License B
•
r • Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
ClTI OF Fax(408)777-3333
OCUPEkTINO
Building De artment
JOB ADDRESS: 111 Ltn�(5 �,ST� p� PERMIT #
C� I-to C?-)7/
OWNER' NAME: 1 PHONE # — ?Z/p
GENERAL CONTRACTOR: (oy c{, to ,_ FAX #
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
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