04070037 CITY OF CUPERTINO a•t; 'I.� 1
BUILDING DIVISION PERMIT WONTRACTOR INP'U'RIVIATION
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BUILDING ADDRESS:227 NIORTHEIROnK So A PERFECT CLIMATE PERMIT"°04070037
OWNER'S NAME: PERMIT ISSUE DATE
SHAT-INT
ONE: SANITARY NO. CONTROLNO.
(408) 861 -954r,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION
1 nanny alarm that l am licensed under pmyaions of chapter 9(cammcncing Job Description
wire Sidon]IXgH ofDivisirn 3 of the Budncu/,I/rofcuin:Code and my lmmm la
in OmRf na ercea $ ADD A/C
111
5q= LiccnayRLiaR
Yq ARCHnECrs OECLA V
Y2 dcrnand my plans shall he used publl rds
DSD
3 G t; Licensed Professional
+� 3 0-1OWNER-BUILDER DECLARATION
f I hcrchy.(Erre that 11. exempt(ram de Comas Co :License
yc Law crime, 'y e
3OO whichfollowing mqui...(Sec0an A131.0.BOhm.sand Pmfexsiom Cook:Any city net.y
a�9 which require a permit m e ices Me eltea Impmw,demolish,.re a signmi m atom
Fly pdI a iuissuancc,aim mquimstW applicant for such Permit filcasigncd smtamcm
thatW isliansed purauanunlhe pmvisiom.fthc Cmuacmrs License law(Chepter9 Sq.Ft. Floor Area Valuation
as (commencingwiith Section 70°0)of Division 3 ofthe Businessand Professions Cock)or
that he u seem t therefrom and Ne basis fm Ne allcgod escalation.Any violation of
ave
Section 7031.5 by any applicant far a permit subjects Ne epplicam to a civil penalty of
not roam than hundred dollars(3500). 3 II&BI3'QlidII0 Occupancy T'pe
❑1,u owner of the property,or my employees with wages as their sole compensation,
will do Ne work and the gmctum Is not intended oroRered fors.].(Sac.7061,Business
and Profesdom Code:The Contractors Limnm law does net apply to an owner of Required Inspections
properly w ho bui Ida or improves thercrn,end who does such walk himself or through his
own emp]oyen,provided that such Improvements am not mutual mof5amd for We.If.
hawevcc Me building rr ImProwment is mid within oro Sear of eompledon.Manama.
builder will have the burden of proving that he did not Wild or improve for purpose of
salt).
❑1,as Owner of the property,am exclusively contracting with licensed amracmn to
comtmet the projem(Sec.7014,Business and Professions Code:)The Convector's Li.
more law does not apply man owner of progeny who Wilds or Impmves themon,and
who contracts for such projects with a coma11014)Ila meed pursuant to the Contractors
Lima.Law.
C1 I am exempt under See ,B&PC for this recon
Owner Data
Aim WORKER'S COMPENSATION DECLARATION
1 hereby a(N n under penalty of perjury,ane of the following d ulmloas:
J I haus and will maintain a Canifiwm of Consent in self-Lr-mefor WmlCamper.
antion,u provided for by Secdan 3700 of the 11,Code,far the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compenudon Imorance,as required by Section
3700 of Ne Loor Caulk,for Ne performance of de work for which Nis permit is issued '
My Workers Camps fade Inaursommasimantl P.1myn bee
Polity-
�TIFICATE EXEM ONFROMWORKER
COMPENSATION INSURANCE ,
(ThB maim need not W completed file permit is future hundred doiy ..g
ICa6)I embfy that in Ne performarcc of the work for which this permit u issuedcmPloy any person in any manners.u to b..me subject to tbe Work.'CoLaws of California.DamApplicant
NOTICE TO APPLICANT.IL after making this Ccnificate of Exemption,become subject to the WOr rb ComKnutioa previsions of oc ubm Code,
., z faMwith comply with such provision or this permit shall W deemed revoked.
z O CONSTRUCTION LENDING AGENCY
[+ I hereby affirm Nu them is a.a ctinn lending agency lot the performance of
Qi r�r the.,it for which this permit is issued(Sm.3097,Civ.C.)
Q Lenders Name
lander:Address
U Q I certify that 1 have mad this application and oak that Ne show infotmadun is
{7. PcormcL l.gree to comply with all city and county Ordinancesand gam laws relating to
C)Ubuilding construction.and hereby aumrdre represenutiws of this city to curer upon me
[17 abuvc-mcmionodprogeny far inarcoies ma
gy (We)agree to save,indemnify and keep harmless me City of Cupertino.gaunt
h lieancou.c., c,hegrantOld narcoses peowhich mryln any way same against said City
(„)`Z in consequertee of the gaming of this permit.
.. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NO NT Issued by: D [e
OU LAT Ns. � 1[f/T/"/ / /
Signuum or Appb ua�ctor am Re-roofs
HAZARDOUS MATERIALS DISCLO BE Type of Roof
Will the applicant or future building Occupant atom or handle he�ou.mamdal
u defined by de CuMnino Municipal Code,Chapter 9.12.and the Health and Safety
mk.Section0Ym 15533(a)] '�`�JJf All roofs shall be inspected prior to any roofing material being installed.
❑Yes �L/No
Will the applicant orif tum Wilding occupant esu equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by dm Bay Area Air Quality Management
District? all now materials for inspection.
❑Yes
I haveread thebma on m4wdalsmquimmenuunder Chapmr6.95ofineCalifor-
niaHailh&Safety Catic,Se 6..505.25533 and 25534.1 undcnund matif IM building
goerr"s not currently how a tenant,that it is my respomm0by to notify t4lo
u' ts whic mmt be met prior m issuan of a CeniGca¢of
Signature of Applicant Date
ownmmam a' tgenr All roof coverings to be Class "B" or better
Community Development
10300 Torre Avenue
i Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS: �mN 0 r7 0037
PERMIT #
OWNER'S NAME: ) n PHONE # TfS- 3 �Jl
GENERAL CONTRACTOR FAX# "(% -$Gz -115t
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
CITY OF CUPERTINO
�m 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 31639034 . 00
DATE ISSUED. . . . . . . : 07/07/2004
RECEIPT #. . . . . . . . .. 26220
REFERENCE ID # . . . : 04070037
SITE ADDRESS . . . . . : 20227 NORTHBROOK SQ
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : SHALINI AINGER
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-0501
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) 861-9545
�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
BENERGY PERMIT FEE 1 . 00 34 . 86 0 . 00 34 . 86 0 . 00
BSEISMICRE VALUATION 2 , 825 . 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 160 . 73 0 . 00 160 . 73 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER '
-------- --------- ------------ ------------------
CHECK 160 . 73 020850
TOTAL RECEIPT 160 . 73
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH 'ELECTRICAL 501 FINAL ELECTRICAL ENERGY
502 FINAL PLUMBING ENERGY 503 FINAL MECHANICAL ENERGY
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
v
CITYNOF C/UP,�ERTINO 2
jR
�UP `
CITY PERMIT APPLICATION FORM
APN # I �` V J` Date: 7
Building Address:
'202-2-9
Owner's Name: Phone #:
t r 18'-Z53- 17 Shu'
Contractor: "1 Phone: License #:
Contact: 17 Phone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect n Plumb ❑ Mech 93'�'
Job Description: �1 a {� G� /
Residential � (x Commercial ❑
For Residential Installations:
Attic 0 1" floor O' 2nd floor❑
Adhere to min setback requirement El
,or Commercial Installations:
eplacement same weight F] Additional weight (structural calcs) ❑
Structural Calculations required for new installation El
New installation Plannin A royal Re wired ❑
Cost of Project: f� _ Type of Construction: Occupancy group;
U0
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft^Floor Area:
New Location ❑ Replacement ❑
Qty. i
A i b e Fee 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
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
BUSLIC Business License BUILDING
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