04060003 CITY OF CUPERTINO '�
BUILDING DIVISION PERMIT CONTRA.0aR� rri � or�
?t.
BUILDING ADDRESS: AAA FURNACE & AIR CONDITIO DI&JH004060003
10226 N PORTAL AV
OWNER'S NAME: PERMIT MUE DATE
Adjh NEBEL RICHARD H AND PRISCI LA1712 STONE
NE: SANITARY NO. CONTROL NO.
(408) 293-4717
7ARC,111TECTIENGINEER: BUILDING PERMIT INFO
PLUMB
LICENSED CONTRACTOR'S DECLARATIONIOb DeBCTi tion
1hereby.RionNn1amliZxcdun roviai sof Chapur 9(commencing p
Se IXNB of Division3of tha Busineu o ssiona COde.and mylicenu is �Buren nuc CHANGE FURNACE L ®jse I LiecLtrm 2004 RCHITECISOECL 'IN �]
2 I undersunJ my plans shall he used as puM1lie recnNs yvAC 1Np �"'
Zi,
u. Licensed Professional
OWNER-BUILDER mDECLARATION
RyRy I hereby.(sero that 1 1. exempt from the GOrelaelCo License Law for the
`OD follwhich requires.Permit
WA 1.5,consumer,slue, mrPmfeefions demolih.or minycity or coumy 81900
k S which)us iris a permit re restheal¢a improve,demolish.m file.sir any,suucure
y�y thi t he is i ensid p rsuaalso n so One previsions of forsucthe Coh permr's Licme,Law(Cha menl
that wiit pursuant to me previsions of the eBuines ss and
elaw(Chapter Sq.F[.Floor Area Valuation
$
(commencingexempt
rmand of Division ortheeged...P...M vi Coda)or
�.. Net h<u exempt therefrom and the buil far rise alleged eump0on.My violation of
Section 7031.5 by my applicant for a permit subjects she applicant an a civil penalty of &• Occupancy Type
not mart man five hundred dollars(ML
❑I,as owner Orrin,property,m my employees with wages u their sole compensation,
will do thewmrk,and 0n,swcm¢u not intended proffered foraale(Sec.704a,11minesa
and Professions Code:The Contractor's License Law dors at apply to an owner or Required Inspections
p mperly who builds or improves demon,and who does such work himself or through his
own employers,provided thatsuch improvements are notiounded at offered foraale.If,
however,Ne building or improvement is sold within am:year ora nni le0on,me nwneo-
builder will haw she burden of proving that he did not build or improve for purpose of
ale.).
❑1.as Owner of the property.am exclusively contracting with licensed contractors to
convect me project(Sec.7044,Business and Profrasions Code:)The Contractors W.
cense law does not apply to an Owner of progeny who builds or improves memon,and
who contracts for such projects with a contractor(s)liansed puuuam to the Contactors
License Lew.
❑1 sen exempt under Sm. .B d@ P C for this mccon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of me following declarations:
I haw and will maintain a Certificate of Consent a self-insure far Worker's Comfort-
on,as provided for by Section 3700 of the labor Code.for the performance of me
w
ork
of the[Abu,Com,for me performance k for which this permit is issued.
1 haw and will maintain Workers Compensation Insurance.ss required by Section
of the work for which this permit is issued.
Worker's Compensation Insurance can for and Policy number am:
'er Policy Na.;
E T ICA ^OFEXEMPI'IONFROMWORL RR
COMPENSATION INSURANC
Qltb union need not Im completed ifthe permit is f orae ddrdlma(510rp
or leu.)
1 cenify that in the performance of the work for which this permit is issued,l shall not
employ any person in any manneru as to become subject to the Workeri Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Ccnifrcet of Exemption,you should
become subject to the Worker's Componsmion previsions of de,Lahnr Code,you must
.,O forthwith comply with such provisions or this permit&hall M deemed revoked.
ti[r CONSTRUCTION LENDING AGENCY
ti (hereby affam
met more is a contraction lending agency for rim perfutnancm or
fY'> me work far which this permit is issued(Sec.3(b7,Civ.C.)
WM Q Lender's Nsmc
2 Lender's Address
(�0 I certify that I haw read this application and sou met the W.information is
it,H caned.I agree Or comply with all city and county ordinances and aur laws relating to
O U building convection.and hereby authorize representatives of this city to enter upon the
4S1 above-mentioned property for inspection purposes.
F IY (We)agree to an.indemnify and keep harmless the City or Cupertino against
cel liabilities,judgments.costs and expenses which may in any way acerae against said City /
V Z in consequence of the granting of this Permit.
v.0 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
ZSO E REGULATIO S,
4 / zgm �,-- AU O!�/�jl Re-roofs
Signature,of pp cmtContact Dau
HAZARD US MATERIALS DISCLOSURE" Type of Roof
Will me applicant or future building occupant sum,or handl3heardour material
as definad by the Cupertino Ngicipal Code,Chapter 9.12.and me Health and Safety
We,Section 25532(a)?
❑Yes All roofs shall be inspected prior to any roofing material being installed.
u
Will the applicant or future building occupant use equipment or dcvius which If a roof is installed without first obtaining an inspection,I agree to remove
It hang us air contaminants as defined by Out Bay Area Air Quality Msngcmcnt all new materials for inspection.
aria?
❑Yes $Nu
I have read me havardolvs materials requirements under Chapter 6.95 of the Califor.
nia Heal"SsfeLYCOdi,Secdcas 25505,35533 and 75534,1 underemnd mat if me building
data not Carmody have a nature.that It is my responsibility to carry 0n,occupant of du
mqm cn hien meost W met poor an issuance ora Ccnific¢u of Occupancy. Signature of Applicant Date
f L,.a.Pafiyiuw. ._ All roof coverings.to be Class"B"or better
Owner or mahmircd agent Dau
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building Department
JOBD ZESS: PERMIT#
G UG !J
OWNER'S NAME: EL PHONE #
GENERAL CONTRACTOR: 4 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
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
PERMIT INVOICE OPERATOR: suem
qw
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 31628057.00
INVOICE DATE. . . . . . : 06/02/2004
REFERENCE ID # . . . : 04060003
SITE ADDRESS . . . . . : 10226 N PORTAL AV
SUBDIVISION . . . . . . .
CITY ... . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER NEBEL RICHARD H AND PRISCILLA
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2354
i
CONTRACTOR . . . . . . _'�RANDO, JIM LIC # 8050
COMPANY . . . . . . . . . . : AAA FURNACE & AIR CONDITIONING
ADDRESS . . . . . . . . . . : 1712 STONE AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408) 293-4717
FEE DESCRIPTION ACCT NUM CHK TOTAL FEE PD TO DATE SAL DUE
________________ ____________ ___ __________ __________ __________
GY 4119 A 23.10 23.10 0.00
ACE INSTALLATION 4117 P 13.25 13.25 0.00
,
SMIC FEE RES 2013 P 0.50 0.50 0.00
MECH PERMIT ISSUANCE 4,117 P 35.52 35.52 0.00
72.37 72.37 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