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08010003 CITY QF CUPERTINO BUILDING DlwsloN PERMIT 'SO T-OR%I):V'F' }RR4AT'IOmoss PI: BUILDING ADDRESS: PERMIT NO. 10727 RANDY LN RESIDENTIAL HEATING AND A/C 08010003 OWNER'S NAME: 1 Eq PERMIT ISSUE DATE GRIFFIN TERRY L AND MARGARET 65 CRISTICH IN 01/02/2008 ONE SANITARY NO. CONTROL NO. 4083774073 ARC HITECTIENGINEER: BUILDING PERMMNFO BLDG ELECT PLUMB MECH I� C= �Op LICENSED CONTRACTOR'S DECLARATION Job Description (j 1 thereby affirm that 1 me licensed under provisions of Chapter 9(rnmmcneSCOcing p with Section 7M)of Division 3 of the Business and Professions Cade,and my lkccmc is REPLACING EXISTING FURNACE n min full forte and yt,, 'lGSS, �t 2 g? "ken Clan `C-� Ile,N 1 n Dau • a Contnnor R ee ARCHITECTS DECLARATION ty� C I underBand my plans shall W used as public records J g red Licensed Pmfeuionsl yg OWNER-exempt RDECLARATION 9 a I hereby.(Sero on 1 1. exempt from the Contractor,Ucrnu Law for t. i.D o following moon.(Salon Icon 1.6,Business and Professions li Cadc:Any city or county $ which requires uae.permit Mau to CONWc"eller,nt rat w,ll Per t rare a sig my edtlmelYm prior biucensed eal,u mqo the dteidom,of the Conpermi'mmcnmaw,(Chapter Cha mem e2F (dual he commecceNeJ pursuant to the of Division of the 9 uacmriLiaNCssons Cru¢r9 Sq.F[. Floor Area Valuation y s (commencing p(ftmf.and drus hu for the tW Businw cia Professions Cade)of $8500 Q .. Nu io u exempt them(rom and the Eur for IW subjects the cremation.Any violation of Salon,ill .3 five sly applicant far a permit mbjeeu Ne applicant m a civil penalty of Number Occupancy e ant mart than raw nuramtl donors(ssam. 316 0 2 0 41!ff P Y TYP ❑1,u awn"of Ne property,m my employees wit wages a thev role compensation. will dote work and to commerce. 4 not intended maw cl forma.(SCe.]0U,BNinw Nd Ptywho W Cade:The Improves trCbr,Llanro live uch or apply lf rt PNNr of Required Inspections propenywWWipGaed tat lutes prove who aoesombwohb offe ed f. I his awn employee,,Provided pr such improvements within are not arofIntended"offered the me If, builder,to Wilding u Improvement 4 cold whin ane year or completion,to awe of tak.). will hew the When of proving that he did not Wiles m Improve for purpose of ole.). ❑1.u owner of the property,sol exclusively contracting wins Immud contractors in construct to project(Sec.7064.Business and Professions Codo:)The Conuuur,U. . cents Law dos not apply m an owner of property who Wilds or improve Lemon,and who comems far,ah pmjeee with a mntranons)Warned purmsnl in to Contracmrs License law. ❑I oro exempt undo See ,B d:P C fm N.tsuon Owner Data WORKER'S COMPENSATION DECLARATION 1 Wzeby ABbm under penalty of perjury on,or the following declarations: 1 haw and will maintain a Certificate ofCansent m tslf-iiuure faWorkers Comprn- on,u provided for by Section 3]00 of to labor Code.for the performance of the ort for which ti,permit is iurcd. )�1 have and will maintain WMmri Compensation Insurance,as enuiutl by Section 37M of the Labor Cada,for the Performance of to work for which this permit is Issued, My Workers Counteraction In urana carrier Will Policy number me: Cartier.IYIQ Je C}h E Po,,,y,..: I . CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE QEr Yetlna sed.olbecomplowd[film Permit Is force.handed dallN(SIM) or less) 1 ani(that in to perfarmame of to work for which tis permit is Issued,I Nall um employ any person in my sooner as to become subject side Workers'Compewdon Laws of Califumis.Date Applicant NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should become Subject to Oc Workeh Compensation provision,of the Labor Code,you cowl O O (~r formoolh comply with such provisions or this permll Nall W deemed evoked. Z'••� FN CONmucrIONLDINGAOENCY IWr by which ism Natter.iasued(S .307,Cingagenry far On performance or Ci theLe work Na whish dtis permit r Issued(Sec.7091,Cir.C) GQ Landeh Nam. �z Larder,Asara, V Q 1 certify that I haves reed this application and Bute bol to above Information la torrent l agree to comply with all city and county ordinance,and Aute laws mining to 0 Wilding construction.and hereby authorize representatives oftis city in rnterupnn the ' W shove-menuanrA property for iNmcdon purpm.s (We)agent to rave,indemnify and kap hanln to City of Cupertino again . ,ay Iiamilltics,judgmenisconaandexpeNu which may manyway amaagsimas id City V z in APPLuence or the Starting of this Permit. ICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date BO CE REGULATIONS. Re-roofs n Sigme of AppliuMComra or Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof WIII the appliam or fMuni Wilting aaupant core mandd do anmaterial ss deONc by the 32(ay M Municipal Cade,Chapter 9.11,and the Health and Safety Code.Section[: lss3a(.n , / All roofs shall be inspected prior to any roofing material being installed. ❑Ya pNa WTII te applicant or.fuluro Wilding occupant use equipment or aevlaa which If a roof is installed without first obtaining an inspection,I agree to remove r husNnN alis conmimms u ne dc0d by me Bay Arta Air Quality Management all new materials for inspection. cls by. I have read the hnsN.0 materish oxi.mmrnu under Chmu r6.95 of the C.5for. ria KuklO&SafctyCeae Sections 75505,25533 sm125534.Imager and tnifte Wilding dos AAAat currently haw•manse tat II r my responsibility in redly On=owl of the cnta which must W rte mmLunsac of a Certificate of Ota aney. Signature of Applicant Date does roof coverings to be Class "B"or better Owner m awnadzea,gem Dau' g u c) CITY OF CUPERTINO FURNACE/AC aOF ® CUPEkT1No PERMIT APPLICATION FORM APN# Date: JAn Building Address: 171011 �o�re� L r> . Owner's Name: Phone#: Contractor: Phone#: 1 1 _--icn3 �s i 6-2 n \�,,� 1110. Fax #: 11 — 12 Contractor License#: Cupertino Business License#: 1�sssti a � � � � Contact: p� Phone#: 3n� clye ► \ �aJ✓LR Fax#: 3�1 �l �lrbs'y Building Permif hifo: Elect ❑ Plumb ❑ Mech Residential Commercial ❑ Job Description: For Resid ntial Install ons: t n Attic ❑ 15` floor �� 1� 26 floor ❑ Adhere to minimum setback requirement ❑ 777��C For Commercial Installations: Replacement same weight ❑ - Additional weight(structural calcs) ❑ Structural Calculations required for new installation ❑ New installation Planning Approval Required ❑ Cost of Project: Type of Construction (Usage Class): Strapped I I On Platform ❑ Bonded New Location Replacement Valuation: Green Building: Must attach Green Building Check list to this application CITY OF CUPERTINO FURNACE/AC CUPEI�TINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group FURNACE FURN/AC 1MCRAA Commercial-Repair/Alteration/Add to M ea heating appliance,refrigeration unit, cooling unit,absorption unit,or ea heating,cooling,absorption or evaporative cooling system,incl installation ofcontrols regulated_by-this code. 1MCREPALT Commercial for the repair of alt/add to M ea heating appliance,refrigeration unit,cooling unit,VAV boxes, absorption unit or ea heathing, cooling absorption,or evaporative cooling sys, incl install of controls regulated by this code. 1MCSUSHTR Commercial InstalURelocate ea M 41 suspended heater,recessed wall htr, or floor mounted unit heater. 1PGASCOM Commerical for ea gas piping System P 1-4 outlets 1BPGAS For each gas piping system of 5 or P more per outlet. 1MCAPPVNT Commercial for the install/relocate/ or M replacement of ea appliance vent installed &riot incl in an appliance permit. 1BSEISMICO Commercial Seismic B 1MRRAA Residential Repair/Alteration/Add to M ea heating appliance,refrigeration unit, cooling unit,absorption unit,or ea heating,cooling,absorption or evaporative cooling system,incl installation of controls regulated by this code. 1MRSUSHTR Residential Install/Relocate ea M suspended heater,recessed wall htr, or floor mounted unit heater. 1MRAPPVNT Residential for the install/relocate/ or M replacement of ea appliance vent install &not incl in an app] permit. CITY OF CUPERTINO a'' FURNACE/AC •CUPERTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group FURNACE FURN/AC 1PGASRES Residential for ea gas piping system of P 1-4 Outlets 1BPGAS For each gas piping system of 5 or P more per outlet. 1BSEISMICR Residential Seismic B 1MECPLNCK Mechanical Plan Check M 1MFR=<100 Furnace Syst<=100k BTU install or M relocate ea forced-air/gravity type furnace/burner, incl.ducts/vents attached to such appliance up to and include 100,000 Btu/h 1MFRN>100 Furnace Syst> 100k BTU install or M / relocate ea forced-air/gravity type ( fumace/bumer, incl ducts/vents attached to such appliance over 100,000 Btu/h 1 EPERMITFEE Electric Permit Fee E 1MPERMITFEE Mechanical Permit Fee M I 1PPERMITFEE Plumbing Permit P 1TRAVDOC Travel Documentation B 1BUSLIC Business License B • CITY OF CUPERTINO FURNACE/AC CUPEkTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group AIR FURN/AC CONDITIONING 1BCAIRHAN Commercial A/C Units <= lOk CFM B 1MCRAA Commercial Mech Repair/alt/add M 1BSEISMIC0 Seismic Commercial B 1PGASCOM Commerical for ea gas piping System P 1-4 outlets 1PGASRES Residential for ea gas piping system P _ of 1-4 Outlets 1BPGAS For each gas piping system of 5 or P more per outlet. Comm/Resid 1BREMAIRHAN Residential A/C units <= l Ok CFM B 1MRRAA Residential Mech Repair/alt/add M 1BSEISMICR Seismic Residential B IEPERMITFEE Electric Permit E 1MPERMITFEE Mechanical Permit M 1PPERMITFEE Plumbing Permit P 1TRAVDOC Travel Documentation B 1BUSLIC Business License B CITY OF CUPERTINO • 7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 31602041 . 00 DATE ISSUED. . . . . . . : 01/02/2008 RECEIPT # . . . . . . . . . : BS000003592 REFERENCE ID # . . . : 08010003 SITE ADDRESS . . . . . : 10727 RANDY..LN SUBDIVISION . . . . . . : - CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . : OWNER . . . . . . . . . . . . : GRIFFIN TERRY L AND MARGARET S ADDRESS . . . . . . . . . . : 10727 RANDY LN CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2054 RECEIVED FROM . . . . : RESIDENTIAL HEATING CONTRACTOR . . . . . . . : CATHY HAIRE LIC # 21161 COMPANY . . . . . . . . . . : RESIDENTIAL HEATING AND A/C IN ADDRESS . . . . . . . . . . : 65 CRISTICH LN CITY/STATE/ZIP . . . : CAMPBELL, CA 95008 TELEPHONE . . . . . . . . : 4083774073 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BSEISMICR VALUATION 8, 500. 00 0 .90 0. 00 0.90 0. 00 1EPERMITFE FLAT RATE 1. 00 40 .79 0. 00 40.79 0. 00 1MFRN>100 UNITS 1. 00 122 .38 0. 00 122 . 38 0. 00 1MPERMITFE FLAT RATE 1. 00 40 .79 0. 00 40.79 0. 00 1PPERMITFE FLAT RATE 1. 00 40 .79 0 . 00 40.79 0 . 00 1TRAVDOC FLAT RATE 1. 00 40 .79 0 . 00 40.79 0 . 00 BUSLIC FLAT RATE 1. 00 110;.Ml 0. 00 110. 00 0. 00 --------- --------- ---------- ---- TOTAL PERMIT 396 .44 0 . 00 396 . 44 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 396.44 #24573 TOTAL RECEIPT 396.44 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 113 SLAB 301 ROUGH PLUMBING 303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL 506 GAS TEST 507 FINAL PLUMBING 508 FINAL MECHANICAL i Community Development 10300 Torre Avenue 1t Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 :UPERTINO Building De artment JOB ADDRESS: 1 O,l I 1 � PERMS #� OWNER'S NAME: Y i 1161 1. PHONEY# 0-13 GENERAL CONTRACTORe-5j (. en ta-hFAX # I am not using any subcontractors.— WVL9� a t�� 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