06120086 CITY OF CUPERTINO
BUILDING DIOISION PERMIT *-C�NTRACTQR INFORMATION" ':,
BUILDING ADDRESS: PERMITNO.
OWNEWSNAME: UE ATE
HELMHOLD DENNIS L AND MONA L 5390 E PINE AVE 12/18/2006
E: SANITARY NO, CONTROL NO
ARCHITECTMNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
o o LICENSED CONTRACTOR'S DECLARATION lob Description
1 hereby affirm that I am licensed ouler plavitioru a(Chapter 9(commencing P
'Z,u wishSeelm.7011U)ofDivision 3afshcBonn.and PrafesaimerCade.alldmylicense is REMOVE AND REPLACE FAU & AC
,<a In fullfaroem e', t.C1A,Qr1 lPgb-Tq5
In= Liccn CID Lic.A DU _L
Dau
Contractor
C ZO+AISC
'o ARCHITECTS Dtor AT10N
w< 1 understand my plans shall W stand as public records '
s u
°OIn Licensed Pm(cssianai
OW NEn,exempt
.DER found
DECLARATION
1<E 1 marso mFrm u m I am,Bumps from the Cssions Coca:
:Any C Law for my
: following reuon.(Sttdue 703 IJ,Business and Professions Calc:Any city or county
:2C
1-414 which remn.a pcsmil to command,alter,improve,dcmnlish,ar repair any mructme,
:Zs prier to its is ander,, I.W beams do,applicant for such permit to file a signed statement
thtalhe is licensed pursuant to the previsions of the Contractor License Law(Chapter9 Sq. Ft. Floor Area Valuation
D (eammeruing with Section 7000)of Division 3 of the Business and Poo(essiosu Cale)at 8 7 6 0
t $ slut W is exempt theafrort aM the basis for the alleged exemption.Any violation of
Section]031.5 by any applicant for a permit subjects the applicant to a civil penally of Number Occu ane Type
nal mom man five hundred dollars(35M. 3 2 618 0 61 � P Y yP
0 1.as owner of the property,or my emplayeu with wages as their=to compensation,
will do the work.and the structure is not intended or offered rmsale(Son.7014,Busistess Required Inspections
and Pmfesumu Code The Cormsclors License Law does reoet apply to as owner of q P
property who builds or improver thereon,and who does such work himxl(or shmugh his
own a
however.
the Wilding
provided mar seen improvements are nal intended moRerW fm sale. r-
builder.the have
t or den of proving
u aaltI within arts rot of complexion,me owe of
builder will have me burden of proving mat W did not Wild or improve for purpose of
Beed.
0 1,as swear of she property.am exclusively contracting with tic nand comncmra to
construct one project(Sec.7044,Business su and ProfaioCode:)TW CommemrS U.
roue taw dote not apply m an ownv of propcny who Wilds car improas demon,and.
who emuratte for men pmjecu witha conuadim(s)licensed purxanl to the Cimmomh
License Law.
O l am exempt under Sae ,B h P C for thus banner,
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby afrum under penalty of perjury one of she fallowing declarations:
1Im a and will maintain a Certificate of common to self-isuurt fm WorkeraCompen-
sation,as provided for by Section 37W of date tabor Code,for the performance of sec
.,it for which this permit is issued.
0 1 love and will maintain Workers Compensation insurance,as required by section
37W of the labor Codc,for the performance of she work for which this permit u ended '
My WmkacAth Compensation Isamu.artier,Ia�tl�[UPoylt'cy number are:
Carrier. ACA yt U eLI-Y y aP liry No.:NW f. Cal"q.(0%q-3q
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ines section need not W completed tithe permit is forma hundred dollare(SIM)
micas)
I canary that in the performance of thc work for which this Permit is issued,l shall not
employ any perun in any manrcrso u In become subject to the Werkeri Compesumon
U.of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exempuan,you should
become subject to the Workers Compensation provisions of tie Labor Code.you most
.J O farmwith comply with such provisions or this permit shall W deemed revoked.
ZtVi CONSTRUCTION LENDING AGENCY
E+ Ihemhy affirm that mere its construction lendingagenry,lbs the performance of
R'I she work Tor which this permit is issued(So:.3097,Civ.C.)
LAI Lenders Name
=z Lender's Address
V 0 1 comfy that I have rod this application and sure that she aWvc let ormafine is
U, cancer.1 agree to comply with all city and county ordinances and sera laws relating m
C U building construction,and hereby audsanm repodendtives orlhis city to enter upon the
oon
move
er.j.dnadpropodu'ter e.per.which a.
H 4 (We)agree to ar demni fy and keep harmless the City of Cupenino against
TA Iiabilitia,jud8mcnts.<osts end cxpcnua which may in any way accmc against said Cisy
U
APPLICANT
NT ofshegrantiN JrA permit. I
^ APPL'ICANi UNDERSTAND ANDvWILL COMPLY WITH LL N N-POINT Issued by:j 6i Date
$ CE GULATIONS.
t�mllnU Ig fir' Re-roofs
m
Sign reof Ap,ddm Contrrcmr Dau
I1HAZARDOUS ALS DISCLOSURE Type of Roof
Ue applicant m futme Wilding occupant state or handle ba rsd W,material
u defined by the Cottonton ,Code.Chapter 9.12,and the Heath and Safety
Code.section 25532(a)7
0Yex All roofs shall be inspected prior to any roofing material being installed.
�o
If a roof is installed without first obtaining an inspection,I a ree to remove
Will she applicant of future Wilding occupant use equipment or devices which g
_nit lorardnus air ronuminxnu a derated by du Bay Area Air Quality Management all new materials for inspection.
District' ��V/f
OppYcs Nu
I have real the ha allous`materials requirements mokochmin,6.95 of the Califon
ria He.]"Safety(don.Section 25505.25533 am125334.1 undoedual thxtifthe Wilding _.
MWJma roently have a tenant the 'tb my responsibility to notify me occupant or she
mqui cntsw Immusl me psi min " aearaeerdareateor adv ar. Signature of Applicant Date
All roof coverings to be Class "B"or better
O crura horizcJ,gem Date'
Community Development
a 4 10300 Torre Avenue
^ ✓ Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS: PERMIT #
/00- ` 00'1Z00e6�
OWNER'S NAME: `,-t o i{ PHONE #
GENERAL CONTRACTOR 'gyp n 1 crl FAX #
I am not using any subcontractors.
Signatuoe 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
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: amyw
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32618061 . 00
DATE ISSUED. . . . . . . : 12/18/2006
RECEIPT #. ... . . . . . . : BS000000013
REFERENCE ID # . . . : 06120086
SITE ADDRESS . . . . . : 10058 OAKLEAF PL
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : HELMHOLD DENNIS L AND MONA L
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1107
RECEIVED FROM . . . . : RECEIPT INTERFACE
CONTRACTOR . . . . . . . : STEVE JOHNSON LIC # 24148
COMPANY . . . . . . . . . . : JOHNSON AIR
ADDRESS . . . . . . . . . . : 5390 E PINE AVE
CITY/STATE/ZIP . . . : FRESNO, CA 93727-2113
TELEPHONE . . . . . . . . :
• 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
BREMAIRHAN NO.UNITS 1. 00 10.26 0. 00 10 .26 0 . 00
BSEISMICRE VALUATION 8, 760. 00 0. 90 0. 00 0 .90 0. 00
BUSLIC FLAT RATE 1 . 00 107 . 00 0. 00 107 . 00 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
PPERMITFEE FLAT RATE 1. 00 38. 37 0. 00, 38 .37 0. 00
-------- --------- ---------- ----------
TOTAL PERMIT 268 .13 0. 00 268 .13 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
------------ --------------- ------- ------
OTHER 268. 13 MASTERCARD
---------------
TOTAL RECEIPT 268 .13
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- -------------------------- ------- ------- --------------------
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL 508 FINAL MECHANICAL
•
CITY OF CUPERTINO
FURNACE /AC owla?00 `a(o
CUPEII;TINO PERMIT APPLICATION FORM
APN# Date:
3a cam- i S—c�c91
Building Address:
10D5& OA EAF EPT.IND CA
Owner's Name: Phone#:
MWA aELIMAOLD4DS - clg - I$
Contractor: License#:
50liNSDN Alp,
Contact: Phone#:
5RAQWJ dA51L.OA L L 41 -0409
Applicant/Contractor:
SO1O P
Building Permit Info:
Bldg Elect Plumb Mech
Job Description:
Residential: k4-k EA to ,j- AC, Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.;
Architect/Engineer: Valuation
Type of Construction: Occupancy Group:
Qty.if
A licable Fee ID Fee Description Fee Group
BENERGY Ener •BUILIDNG
BREMFURN Relocation'ofFurnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAUUJAN A/C Units <= 10,000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch &Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMTTFEE Mech Permit Issuance MECHANICAL
PPERMTTFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees EWBPLANCHK Plan Check Fee BUSLIC Business License