05070165 CITY OF CUPERTINO �•*%: - .+' 7* "r^ �-" '9dxeaa "* '
' BUILDING DIVISION PERMIT aCON'CRAGTOR INFuORMATIQN "
BUILDING ADDRESS:- A PERFECT CLIMATE PERMITN0.05070165
Q21gC F AAF
�R'S NAME: PERMIT ISSUE DATE
. EILEEN VIEIRA lOS70
PHONE: SANITARY NO, CONTROL NO,
408) 861-9545
ARCHITECVENGINEER: BUILDING PERMIT INFO
- BLDG ELECT PLUMB MECH
0 0 0 0
°oo LICENSED CONTRACTOR'S DECLARATION Job Description
4U❑ I W reby affirm that 1 am licensed under provisions of Chapter 9(commencing p
�W wiI Scction9IXX1)mfpivision3of the Business and Professions Crede.andmyliccnuu FIIV A ��®
inruBmneAnd es '3 INSTALL FURNACE Y/A�►
p ra Liccn las Lic.N
Cumr r
reemda
Its OcrsunJ myNJ
ARCHITECTS
EC SDEpu CATION 1
s G N cert d Professional .
-S�f/' 2005
'u,'
.�-3 OWNER-BUIIDER CLARATION Gt/�l�®ING 1283
i X I hereby affirm Not I am exempt fmm the Contractor's License Law for the
p O following mason.(Stevan II131.5,Business and Professions Code:Any city m county
T'$ which requires a Permit to erenavuet.alms.improve demolish.or repmr my structure
-Z.j, prior m its issuance,also requires the applicant forsuch permit m Rte a signed sutemem
< that W is licensed pur®ent to the pmvisims of the Contractor's Uceme Law(Chapter 9 Sq.FL Floor Area Valuation
YHA (commencing with Section'IOfp)of Division 3 of me Business and Pmfcasians Cook)or
y
Out he is exempt therefrom And the,beau for the alleged cuntpt int.Any violation of
Section 7031.5 by My applicant for a permit subjects We applicant in a civil penally of
not mom Nan five hundred dollars($500). r Occupancy Type
❑I.As owner of On,property,or my employees with wages As their role compensation.
will do the work.and On structure is not intended or offered for sale(Sec.7041,Business
and Professions Cade:The Contractor's License law does not apply m an owner of Required Inspections
property who builds or improno Memos,and who doessuch work himself or thmugh his
own employees,provided that such improvements we not intended ora@red forsaln If,
however.Ne building or improvement is sold within oro yew of compleuon,Ne owner.
builder will have Ne burden or proving that he did not Wild or improve for purpose of
ask).
❑1,as owner of the pmpcny,am exclusively contracting with licensed contractors in
construct Ne project(Sec.]Odd,Business and Profession Cade)The Contractor.Li
cense Law does not apply 0 an owner of pmpeny who Wilds or Improves NtRan,and
who contracts for such projects with a contra mu(s)licensed pursuant to Ne Convenor's
License law.
❑l am exempt under See. - B J,P C for this mason
Dam
r. ......_ .. : . :.. .':_
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury arc of the following daularali ins: .
❑I have and will maintain a Cenifcam of Conserv to self-imum for Worlteri Compen-
MAN,as Provided for by Section 37M of the labor Code,for the performance of Ute
work for which this permit is issued. '
❑1 have and will maintain Workers Compensation Insurance,m nquined by Section -
37W of the Labe,Code,for Ne pertoorimmc of On work for which this permit is issued.
My Worker' Compemauon lnwnnce artier Md Poliry numberam: I,
Cartier: ✓r✓I 0,#A Policy N..;!!
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This secunn reed not Mcompleved if tie permit is formic hundred dollars($100)
or less.)
I conifv Nat in the performanec of Bic work for which Nis permit is issued.I shall not
employ any person in any manner as as to hecome subject to ON Workers Compensation
Laws of Califemia.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should
become subject to IM Worker's Campe eamen pmvWw,of the labor Code.you most
.JO TOnhwl the comply with such provisions or this NoMil shall he deemed invoked.
'z CONSTRUCTION LENDING AGENCY v
[-t I hereby atfrm Nat there is a construction lending agency for the performance of
a the wish for which this permit u issued(Sec.309y,Civ.C.)
Q LendcYs Name
z Lcndefs Address
U C) I ccdfy out I have read this appfe.fmi and sum Nat she above NfomaWn is
I2.P correct.I agree to comply with all city and county ordinances and sum laws rtlaung to
CU building conswcuon.and hereby Andiron representatives of this city to enter upon me
Move-mentioned property for impecuon purpoka.
F 1 (We)agree to save,m4crunify and keep harmless the City of Cupertino againw
N liabiliues,judgmcnts.costs and cxpcmu which mayjo-e way a<rncagainn said City
t_)Z in consequence of the grinding of Nis permit. �
" APPLICANT UNDERSTANDS AND y'ILL COMP WITH ALL NON-POINT Issued by:3 * a Date ?- 5L6/,. OJ�
SOUR REGUL&41ATIONS.. -, /a � 7 1&--a
cs�
Signnurc ofApplicanvComuscirDam Re-roofs /J ai,(
HAZARDOUS MATERIALS ISCIASURE Type of Roof
Will On applicant or future building occupant.Chapt atom or handle hazardous And
tlefrned by the Cupertino Municipal Cade.Chapter 9.12,and the Health Md Safny
.Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
F7 Yea 'mNu
r/� If a roof is installed without first obtaining an inspection,I agree to remove
Will Nc epplicam o furore byyyyyyIlBIIBll11ding occupant sex cyuipmcm or devices which g p
coil havardova air contaminants MCJ by the Bay Area Air eranly Management all new materials for inspection.
Diwictt
❑Yes
1 have resJ the hasardousmatenals requirements unJerChaper6.95 of Ne Califon
no Health At SafctyCodc.Sccvom 25505.25533 wM 25534.I understand thwifthe Wilding
dos not commonly have a tenant them it is my responsibility,m notify Ute acupmt of On
�'romqui cmawhichmustWmclpnurwiuum arc mor@eanmry. Signature of Applicant Date
_e,ncw To Signature
ownes armthad/eta agent p,m All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY
Fax(408)777-3333
100U
Building Department
JOB ADDRESS: &Wz/-'Lnd PERMIT #
10 D&VL �b1 st
OWNER'S NAME: l SCJ PHONE # - t Y
GENERAL CONTRACTOR ' cj=e - F
I am not using any subcontractors: A41 /_k ° i a� 7-0c& -tri
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
oil 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
.Item 1 of 4 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 35718031.00
DATE ISSUED. . . . . . . : 07/26/2005
RECEIPT #. . . . . . . . . : 30520
REFERENCE ID # . . . : 05070165
SITE ADDRESS . . . . . : 10216 ORANGE AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : EILEEN VIEIRA
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
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
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW HAL
__________ _____________ __________ __________ __________ __________ __________
BPERMFEE VALUATION 1,283.00 83.16 0.00 83.16 0.00
BREMFURN NO UNIT 1.00 14.31 0.00 14.31 0.00
BENERGY PERMIT FEE 83.16 39.92 0.00 39.92 0.00
BSEISMICRE VALUATION 1,283.00 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 253.00 0.00 253.00 0.00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL
CITY OF CUPERTINO
FURNACE/AC
cOf
_
CUPEkTINO PERMIT APPLICATION FORM
APN # 67 1
91d,3 Date- /3 -as-
Building Address:102L C�
1
Owner's Name: Phone #:
VI *1 ram
Contrac one: license #:
0) r�a 3 j 5
Contac hone:. Cupertino Bu mess icense #:
nC�c NY 0,
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description:
r
Residential Commercial ❑
or Residential Installations:
ttic ❑ I" floor ❑ 2"d floor❑
Adhere to min set back re uirement
For Commercial Installations-
Replacement same wei;Zt dditional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project:4 12&•z5D Type of Construction: Occupancy group:
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New LocationjPE Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfin 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 I Business License BUILDING .