00120034 (2) CITY,OF CUPERTINO, . '
LBUILDING DIVISION PERMIT CONTRACTOR INFORMATION - '
BUILDINGA 5' �
� i�r0 COLONY HIL_L5 I AVALLEY HEATING &• CLiC] LNG 0012.003A
OWNER'S NA APPLICATION SUB DATE
NAF
.TAMES P ,JR AND NAN '" 0 11 71.' Isl Z4 �l'H Sl` . 12/0642000 ,a
74jARCIftTEC1/HNC.1NIdiR
NE: + . ' ' SANITARY NO. - CONTROL NO.
(408)c',�4-6290 . .
: - BUILDINGPERMITINFOBLDGELECT . PLUMB MECH
LICENSED CONTRACTOR'S DECLARATIONoto
i ' Job Description1 nor 770 of i I I 1 h,B u c P f Ch o 9( ,come y ng
pzhs t eard ra 3 rm.ea Ir r tn.'e de dnyrur.eanti < am e, REPLACEMENT f UP,NACE
n _w3eu
C ntmemr N
ARCHITFCT'S DFCI ARAT
'gaC�O� 1 J .n d ty Elan,sued he used I,p nr acord,
4 E p O
Licaused I Ics.ioml
OWNER-BUILDER DECLARATION
Ihereby iffirin,ht1 "lionan the Contractors Licluse Law far the '
C'(< fall g (Sector,70315 Bunnics,wid I'mmi,irims Colic:A y 'g alciatirty `
F❑
which Tortillas a peraidI t I Imr,ina,muvc,d l.h,or rc,aur itya pure a
3 m pno to it, q tl ppl' tf hp f1 filla g d.t ferent .
that he Iptarticath.theantionannA fdr,Contractors Li,cm,Law(Chptar9 Sq. Ft. Floor Area Valuation' -
(cna caring vah Section 7000) 1 Dwikiaa 3 cI th.Business and Procesoican,Code)
or that he a cxcnpl muefnm and the bask fa he alleged exenlmn Ary violation '-
cNeclua lS hyanyapplicaut haspermitathloo flarp,dicarams,tvil Pratt "
If not mere man file hundred dollar;($500), - - APN Nmnber Occupancy Type
01 I tho pmpeny,or my crophlyall wilh il it,their sole compensation, 355$28041.. X10- z '
will d m k d'her t tintended - « d but ohe ,
Bun 'd Profession,:. Code'TM1 Contractor's L Law d ,apply In an Required Insppfictions
crofainpiany Who builds or aurprovesdieter,and Whod n Workhimself ',- 301 ROUGH PLUMBINGOrth t t gh his(sin yces,r ar Pmv dud that such tip even t oro,lucnded of - .
offered for sate.If.hnwevfir,the budd'Ing nr hnprcvmmmt is sold within ane yea,of 303 — ROUGH MECHAN:I CAI:.
- completion,the inner-hander will haverhe burden of PuMngthut hedid not built '
tnprnne for......a nf,ale').:, _ 3& , — ROUGH ELECTRICAL_ -
oi of p}p ryano exclociively contractingwthlcarmdctinmamrnm 505 — 'FINAL El_ECTRTCAI.:. "
continua,th project(Sar.9(94'B : I P f ,lou C d )Tl Contractor's - r
ue 1 due,act Iplyt rerofp I ,y hobuld, P beaGerona, .507•' - FINAL F'LUMA,T,.(�IG.:.^
rad who contrast,for such proj&s'with a ec acuhas,).u,,,xad'pnrsuant.,nme ' D8 - FINAL MECMAhI I CAI_ -
Contractor',Ucco,e Lax%. .. - - a 51 -
O,1.mIscrota tilde rSec. ,'B&P C bar,Msmason -
Owder• .- Dim .. _ .
r, WORKER'S COMPBNSA'f[ON DECLARATION .
•- 1 arm by affirm under penalty of pe Jury tine of the fallowing declamliaro:
1 have�and will maintain o.Cer,ifcam of Consent to self-insure for
on P - f a pr I d r by Section 39101 f Ih .Less), Ct de, f the -
Elria e Ih kf Ih
' tl'. pal t ed
❑I
hive andwillart' Walker',t rpc I is - 1 reclinedbYSnm nn - s
n❑ f Ih Labor
ar Cud ,1 f part f the k f Iri
' h,hl. p ,'s
.. '
iso nod ,M/y�W l r C r I�c(rypj1 m dpPODI'y b�cryu�rc..(
car' , 05AlY Polo,No
ba✓Oo0%al+
CF.It I'IIrI .U"OF LXEhdEoGN FROM WORKE I2S • O
+
COMPENSATION INSURANCE s • 'Q'," -
`
This section court oat be mntplemd if the,pennll is far core hundred doll...
($IW)at la".) - � - '
1 cenify Ihat in the perfornwnce or the work for which this permit is issued,i
shall not omploy any person in any.manner so as to become snblcer to the Workers P -
Cnup,madun Laws of California.Data - v„ t' ' - "
, APplica aL -
NOTICE.TO APPLICANT:If,after making this Cendr.ho of Exemption,you.should -
becume suhjec,u,the Worker's Compensation provisions nr,he Labor Code,you must
I Imcith comply with such provisions or his permit shall hedecmed.evoked.
z rn
4 ic CONSTRUCTION LENDING AGENCY �
a > IIhereby affirmthat th -is a oundractiA leafing agency for the perfm nonce
-
W E •oftl -workfor which this ,ratit :issued(See,3(19,Cie C)A.
Lender's Name- _
11. z. London,AddroO _ a .. ..
C.1 0r I c try tlr t 11amo cut this ap,heallon and state that the h informationis
Fzl E,t corrc I 1 a,fie to comply telco all city and county on re tee: d ,, xs mill lg.
V tobuilding conocklion,and hereby umnuze represenm,ves uddiscalym emerupon -
'y W ,he above-Inescamed propcny for im,caon porpoises. F t is
-
�;y liob 1 f(W) g , : d ry dlo ph I: II C'CityIC po ri to agars, -
rG
judgracts.costs still expenses which unly in any way arcm,against said , +
C„1 4' city- :i awof,h f e thiel t. , - ,I. (t`1 �[(]/.�/.
SPPLICAR U ART DS jWILI COMPLY W1Tf{ALL NON POINT 1SSUed y: , � ' , Date r, Q:'-
•+' T��
:SigaAppinmUContl-acmr. Date Re-roofs
t am 'HAZARDOUS MATERIALS DISCLOSURE
Will - -
.Wi 'lheapphcemorfnmmhuilifir,&cupandureorhandletarntana,mared,d Type of Roof; _
as defia,d by me Cuponimr Municipal Code,Chnpter 9.12,and the Hwdth and Sider r R•:
Code,Sermon 25532(a)R -
❑Ye.;. ❑No . _' '• All roofs shall be inspected prior to any roofing material being installed. -
Will the apprle.n,or fill I I Idmg oan...at mo o,cipl,rem or devme�which If a roof is installedwiihout first obtaining an inspection, I agree to remove •
emit nazardans eir containinants as dcOned by me Ray Area Air Quality Maorgeurenl. :• -
Distrier' .. all new materials for inspection: Applicant understands and will comply.%ith
❑vee • ❑No t ' ` • all non-point source'regulattons,- •' - ^
I It a e I the h d materials equ rc neat,and,CI',a -0 95 of Ihe' t;
C.IiforiIHeal,h&Sof tY C,da,Svct'ons 25505.25533 and 255341undcr.nnA that -
,iflhchuldnydesnnl' tlyh ., I ,b, ti: y .p 'b'I'ty„nn'fy rhe
,c u1 t f,n u r t: I' 1 nus,h an p t issuance f a Cod hcme ofSignature-of Applicant Date f
Own author.qag til Dam All, coverings to.be Class or better,'
OFFICE r
CITY OF CUPERTINO
1 of 1 BUILDING PERMIT RECEIPT OPERATOR: nancyc
COPY k 3
Sec: Twp: Rng: Sub: Blk: Lot:35928041.00
DATE ISSUED. . . . ... : 12/06/2000
RECEIPT 0. . . . . .... : 14193
REFERENCE IO # . . . : OD120034
SITE ADDRESS . . . . . : 1040 COLONY HILLS LA
SUBDIVISION . . . . . . .
CITY .... .. .. . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER .. . . . . . . . . ..: TODD JAMES B JR AND NANCY R
ADDRESS ... . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5802
RECEIVED FROM . . . . : DAVE C
CONTRACTOR . . . . . . .: ATKINSON, THOMAS LIC It 141
COMPANY .. .. . .. . ..: VALLEY HEATING & COOLING
ADDRESS ..........: 1171 N 4 TH ST
CITY/STATE/ZIP ...: SAN JOSE, CA 95112
TELEPHONE ........: (408)294-6290
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW SAL
BREMHEAT NO OF HEATERS 1.00 6.11 0.00 6.11 0.00
MPERMITFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00
---------- ---------- ---------- ----------
PERMIT 41.63 D.00 41.63 0.00
D OF PAYMENT AMOUNT NUMBER
--------------'" ------------ -----------".___-_
CHECK 41.63 7962
TOTAL RECEIPT m .... 41.63
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
........ ............................ ........ ---..................e......
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL
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