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04100024 CITY OF CUPERTINO" f. BuamNaDIVISION' PERMITO1Re�CTQRT1�TkUtMATItN a;t R*> BUILDING ADDRESS: SUPREME AIR SYSTEMS PERMITNO. OWNER'S NAME: - PERMIT ISSUE DATE INE: SANITARY ftkOL 10. ARCHITECT/ENGINEER: - _ BUILDING PERMIT INFO _ BLDG ELECT PLUMB MECH �o Zp LICENSED CONTRACTOR'S DECLARATION _ Job Description - - 1 Wrah affirm unt I em lismnxd unJcr provivons of Chapter 9(commencing _ With Section 7000)of DiAs m".1'the Busine nand Profcuiuns Code,and my license is _ SLk,p License Class tnmBmmwreeff `' WALL HEATER REPLACEMENT o n Dam ConRacfor p ARCHn Ecrs DECLARATION a I understand my plans shall be used ss public..Me Y;Qu Licensed Professional - j OWNER-BUILDBR DECLARATION eI I harshly affirm Nat 1 am exempt fmm the Contmmor;License Law for the E a2 following mason.(Section 7031.5,Business and Professions Code:Any city or county K m_ Which main.a permit to erosional,eiu r.impmw,demolish,Or mind,any atrealmo poor to its issuance,also requires the appimernror such permit to file a signed statement < that he is licensed pursuant m the prevision;of the Contionor's License Law(Chapmr 9 Sq.Ft. Floor Area $ (commencing with Section 7000)of Division 3 Of the Business and Profcasirns Code)or ey.. that he is exempt feemfrom and sire basis for Ne alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of 3-ATV5ft*gr0 0 Occupancy Type . not marc than five hundred dollars(5500). ❑1,as owner of the property,or my employees with wages ss their sole compensation, will do the work and dw,mmure is not intended or offered for sale(Sec.7044,Business Required IDSpeCCIODS and Profession;Coda,The Connector's License Law does not apply m an owner of ^ - x— — pmpeny who builds or improves thereon,and who does such work himself.r through his own.,,use employees,provided throvonemprowmenu ism n...year Of ar.fferetl Assault.thm own If, FINALE D however, e buildingde improvement is sold within one year d d araftemd Ne Owren . builder will have the burden or proving that he did not build or improve for purpose of m .). .as owner of the property,am exclusively contracting with licensed coenacmrs to OCTQQ /. onswcl the project(Sec.7044,Business and Prof es' s Code:)The Co flowtv's Li. CZX 2094 mise Law docs not nPly tom owner a minty it r' ova th n.and ' who contmcu for suchp ac tis tractor c ton commutes v an.LaW. BUILDING 1 ans axe er Sec C for is ' O n ate WO K COMPENSATIONOEC R —� 1 hereby affirm under penalty of perjury one of the to owing declanllons, " I have and will maintain a Cenifscam of Consent o self-insure for Workers Compen. - --'--- — sa ion,as provided for by Section 3700 of the labor Code,for the performance of the work for which this permit is issued. ❑1 have and will maintain Worker's Compensation Insurance.as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Worker's Compensation Insurance canter and Policy number am: Cartier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE r (This auction need not Wcomplead irthe permit is fnronchundred dollars(51 W) or ears.) 1 certify Nat in the performance of the work for which this permit is issued,)shall not employ any person in any manner so as to become subject to the Workers'Compensstion Laws of California.Dam Applicant - NOTICE TO APPLICANT:IL after making Nis Cini ficme of Exemption,you should become subject to the Worker's Compensation provisions of be Labor Cade,you most �Z forthwith comply wife such provisions or this permit shall be decreed revoked. Z,t O CONSTRUCTION LENDING AGENCY 'r+ I hereby afore that them is a conswctirn lending agency for the performance of (� Its,work(tar Which this permit is issued(Sec.3097,Civ.C.) . 6Wi Q Lenoir,Name a M Lenders Address V Q 1 certify that 1 have read Nis application and stare that the shove Infomtatiun is F correct.I agree to comply with all city and county on inmces and state laws relating to (]V building construction,and hereby authurim repwatentatime of this city to enter upnn the W ahow-mentioned progeny for inspection purposes C (We)agree to save,indemnify and keep harmless the City of Cupertino against ti rA liabilities.judgments.casts and expenses which may in any way accme against said City _ C.) I.APPLICANTeUNDERSTAN Permit.of this Permit. coM WITH ALL NON-POINT Issued by: Date SOURC ATIO D -IUOES a[ApPlicanVComrecmr Dara, HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant ar future building occupant store or handle hazardous material as defined by the Cupentno Municipal Code.Chapter 9.13•and the Health and Safety caJc,Section 255324)? J All roofs shall be inspected prior to any roofing material being installed. C]Was /Nrvo - Will the applicant or future builJing occupant um cyuiPmcnl_or devices which If a roof is installed without frost obtaining an inspection,I agree to remove.- .it barardrus air contarrimmas as Jefincd by rhe Bay Area Air Quality Managcmc a all new materials for inspection. Dwrict? aa....��••YI ❑Yes N. 1 have matl fee harardrus maaoalsmquimmcnu under Chapwr6.95 of the Califor- niaReal GSafety Coda,Sections 25505,35533 md25534.I undersand thatifthe building Jots net currently haw a unans at" y pomihilil mnrdl'ythcoccupmt.fihe m m m.srb art .rs na¢oroccupancy. Signature of Applicant Date Owner.,nthadradagent Data O All roof coverings to be Class"B"or better �., Community Development 10300 Torre Avenue J, Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 �UPERTINO Building Department JOB ADDRESS: PERMI-'F,# Zif D �J � OWNER'S NAME: p£ ` PHONE # — 7V-5� ' GENERAL CONT OR: SUS S AX # 4o - 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 el £ Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock . Til M' Owner/Contractor Signature Date T CITY OF CUPERTINO WATER HEATER CITY OF CUERTINO PERMIT APPLICATION FORM APN# Date: 3 if C7 —. f – O Building Addre s: IDsa Owner's Na e: ` C Phone#: C, ©cf 31S3a7� Contractor: Phone: License#: S �!N Contact: Phone:11Cupertino Business License#: Building P rmit Info: Bldg ❑ Elect ❑ Plumb ❑ Mech ❑ Job Description: Residential !gj Commercial ❑ Cost of Proj t: 61Oo Strapped ❑ On Platform Bonded ❑ 41 New Location ❑ e lacementX Qty-y-,, A ca Fee ID Fee Description Fee Group BPWHEATER Water Heater/Vent BUILDING PPERMITFEE Plumbing Permit Issuance PLUMBING BENERGY Energy BUILDING BUSLIC Business License BUILDING X z73 ° 7 CITY OF CUPERTINO m 1 of 1 PERMIT RECEIPT OPERATOR: conniew COPY # 2 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 37515012 . 00 DATE ISSUED. . . . . . . : 10/05/2004 RECEIPT #. . . . . . . . . : 27307 REFERENCE ID # . . . : 04100024 SITE ADDRESS . . . . . : 10290 MORETTI DR SUBDIVISION . . . . . . CITY IMPACT AREA . . . . . . OWNER NOEL & PATRICIA CLARKE ADDRESS 10290 MORETTI DR. CITY/STATE/ZIP . . . : , RECEIVED FROM . . . . : NOEL CLARKE CONTRACTOR . . . . . . . : ALLEN SENNERT LIC # 21614 COMPANY . . . . . . . . . . : SUPREME AIR SYSTEMS ADDRESS 80 GILMAN AVE, #1 CITY/STATE/ZIP . . . : CAMPBELL, CA 95008 TELEPHONE . . . . . . . . : (408) 376-0406 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- BENERGY PERMIT FEE 1 . 00 34 . 86 0 . 00 34 . 86 0 . 00 BPWHEATER PER HEATER 1 . 00 10 . 79 0 . 00 10 . 79 0 . 00 PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 84 . 02 0 . 00 84 . 02 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- ------------ ------------------ CHECK 84 . 02 7100 TOTAL RECEIPT 84 . 02 VOICE ID DESCRIPTION VOICE ID DESCRIPTION 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING