05070200 (2) CITY-OFCUPEWrINO > '
BUILDING DIVISIONPERMITCONTRACTORINFORM'ATI , N
k
BUILDING ADDRESS: HUSSEY BROS INC PERMIT NO.05070200
ER'S NAME: PERMIT ISSUE DATE
CATE THOMAS M AND EDNA P 640 TAYLOR AVE 07 /29/200S
PHONE: SANITARY NO. CONTROL NO.
(408) 733-6360
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
_Nqo AL
flog(_��po 0
lxpcp LICENSED CONTRACTOR'S DECLARATION Job Descri hong Q5,�f1 E ll
ad C 1 Mrtby efrrm Nu 1 am lived under pmvision5 of Chapter 9(commencing - Dp [t tl cul I LIISo HL'�s'a iILJtl
'ci with Section 70kd.f Division 3ofihc Business and Professions Code.and my license is
m in fullfnaeendcffeer.Ct,t0 Gs, REPLACE FURNACE & A/C
pg? Llcenu'r'/'•�s�CO.
Date t 1
ARCHITECT DIr ECLARATIONu_ 73
C I undcrseand my plans shall W used as public meet& 1k[�
'6D ✓ULD
c tV Licensed Professional a�
`05 OWNER-BUILDER DECLARATION n��T,'i,�!,/,
no 1 hereby affirm on 1 r.3 exempt from the Contractor's Co License Law Int the
00 which
gmresa paccdun 7rl]LS,Business and improve.
m'uns Code Any city or county
$ wM1ich requires a pertnit m cov=et.alter,impmm.dcmolLxh,Or mpnir any l=essee $7600
u—to prior to its issuance,also inquires the applicant for such permit to rile aligned sediment
that he is licensed purstionuothe provisions ofthe Consrncmr'sLianse Law(Chapter 9 Sq.Ft. Floor Area Valuation
YF$ (commencing with Section 7WO)of Division 3 of the B usiness and Profeasions Codd)or
y _ that be is exempt dMrcfrom and the basis for the alleged exemption.Any violation of
Section 703 1.5 by any applicant for a permit subjects the applicant o a civil penalty of APW NUMEki; 0 0 Occupancy Type
not max than five hundred dollars($500).
❑Lasownm of Ne propcny,mmy cmployca with wage utheir ale eompewdion.
will do the west and the structure u notinxrWed or offered(orale Dec.7061,Business
and Professions Coda:The Concocdorl Lice=law dors not apply to an owner of Required Inspections
pmpeny who builds orimproves dmercon,and who kis such warkhimulf orthrough his
own employ=,provided that such improvements art not intended moRered for We.IL
howevu,the building or improvement is sold within and,leu of complation.Ne owner
builder will have time burden of proving that he did not Wild or improve for purpose of
ale.).
O 1,as Owner of the prupeny,am exclusively contracting with licensed contractors to
connroct the projeO(Sec.706,1.Business and Profeuiore Code:)The Comautor's Li
cense raw does not apply to an owner of property who Wilds or impmves thereon.and
who concocts for such projects with a co muntor(s)licensed pursuant to the Convutor's
License Taw.
❑I am exempt under Sec. .B&P C for this reason
Far Data
WORKER'S COMPENSATION DECLARATION
1 hereby a fires under penalty of perjury one of Ne following declarations:
I ham and will maintain a Certificate of Cmuent to ulbinsure fm Worka(sCompen-
atian.a provided for by Section 3700 of the tabor Code,for IW pdrformance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as myvimd by Secuon
37W of the labor Code,for the perfarmaec of the work for which the permit is issued.
My WmWx ComlJh'� ation Insurance nater and Policy number art:
Cairier: �I`VCIC, �CATE F EXEMPTION
Policy R.: WORKERS�
CERTIFICATE OF COMPENSATION
NFROM WORKERS'
COMPENSATION INSURANCE
(Tru section need not becompletoJ iDW permit is for one hundred dills($IN)
or Ica.)
1 cm ifv that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner u as w become Subject o the Workers Compevauon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making Nis Ceniftcate of Exmpdion,you should
become subject to Ne Worker's Compensation provisions of the labor Code you must
.J 0 sh
forthwith comply with such provisions or this permit all W dammed revoked.
Z" CONSTRUCTION LENDING AGENCY
[—i T hereby affirm that there is a covtrurtinn lending agency for the performance of
C4 7 the work for which this permit is issued(Sec.3W7,Civ.C.)
iT] Lando',Name
Lenders Address
_D a7.
V O 1 certify that I have read this application and sate that the about information is
ly — trader.I agree to comply with all city and county drummers and sure laws elating to
pU Wilding cowruction,did hereby mNorim¢preaenutivss of Nu city to enter upon the
r~U abem
ve- entioned property for inspection purpmcs.
CL
(We)agree to save,indemnify and keep harmless Ne City of Caption.against
Frn liabilities,judgments,casts and expenses which may in any way accrue,thwart aid City
V Z in crnxgmnete of date granting of this permit.
APPLICANT UNDERST S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATION /m 2-9_0r
IVa1 Re-roofs
signature of ApplicaData
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF
Will the applicant ser(mux building meupanumxor herdiceallousmorial
to
as refined Section
the Cupertino Municipal Code,.Chapter 9.12.and IM Health and Safety
.ak.QYus 255)2(x)?;_AN. All roofs shall be inspected prior to any roofing material being installed.
Will Ne applicant or(wore building occupant sou cyvipment or dews=which If a roof is installed without first obtaining an inspection,I agree to remove
crit hazardous air coneminan as defined by the Bay Area Air Quality Management all new materials for inspection.
DistriC17
❑Yes No
I have mad the hva anus materials requirements under Clepmer 6.95 of Om Califor
ria Hca W&Safmy Cade,Sections 25505.25533 and 25536.1 undersand thatifthe Wilding
docs not currently bre itc e tht u is my mspovihility,to notify the acupant of the
requirements wldmnm hnanlp➢orm iveanem or Certirimatt of Occupen . Signature of Applicant Date
Owner ser authorivcd.,Cr( All roof coverings to be Class"B"or better
Daa
CITY OF CUPERTINO
I 1 of 1 PERMIT RECEIPT OPERATOR: kiersaw
COPY # 2
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 36206007.00
DATE ISSUED. . . . . . . : 07/29/2005 ,
RECEIPT #. . . . . . . . . : 30574
REFERENCE ID # . . . : 05070200
SITE ADDRESS . . . . . : 1105 ELMSFORD DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CATE THOMAS M AND EDNA P
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4908
RECEIVED FROM . . . . : HUSSEY BROS. INC.
CONTRACTOR . . . . . . . : HUSSEY, STEVE LIC # 20758
COMPANY . . . . . . . . . . : HUSSEY BROS INC
ADDRESS . . . . . . . . . . : 640 TAYLOR AVE
CITY/STATE/ZIP . . . : SUNNYVALE, CA 94065
TELEPHONE . . . . . . . . : (408) 733-6360
•
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
BPERMFEE VALUATION 7, 600.00 147.96 0.00 147.96 0.00
BREMAIRHAN NO.UNITS 1.00 10.26 0.00 10.26 0.00
BENERGY PERMIT FEE 147.96 71,.02 0.00 71.02 0.00
BREMFURN NO UNIT 1.00 14 .31 0.00 14 .31 0.00
PPERMITFEE FLAT RATE 1. 00 38.37 0.00 38.37 0.00
BSEISMICRE VALUATION 8, 000.00 0.80 0.00 0.80 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 359.46 0.00 359.46 0.00
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ____________ __________________
CHECK 359.46 24838
TOTAL RECEIPT 359.46
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL
Community Development
'+ 10300 Torre Avenue
140,
J Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fac(408)777-3333
®UPEkTINO
Building De artment
JOB ADDRESS: IIbs 1111S P 0 r- PERMIT
7f�2ov
OWNER'S NAME: t"e, caff PHONE #
GENERAL CONTRACTOR: v & FAX # Yi d 7D t-s-i49 n
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
Elec 'cal
Excava 'on
Fencing
Flooring: CarKting
Linoleum/ Woo
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractignature Date
09DIODC O
among, CITY OF CUPERTINO
FURNACE/AC
*CUPERTINO PERMIT APPLICATION FORM
APN # Date:
,3Coa- cam- ��
Building Address: r
NOS- CIV.,"34t7 0r-
Owner's Name: /k 0 0 I c q9/ph e .
� — :)969 Q O q
License Contractor: a ( Li #-:I iO
�wsse ros. � 7.S-G6
Contactm- 1 1 VSSQ Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect Plumb Mech
Job Description: nn
I'eP k 0
Residential Commercial ❑
For Residentialns llations:
Attic ❑ ls` floor 2"d floor❑
Adhere to min set back requirement E]
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Re uired ❑
Cost of Project:7&0i Type of Construction: Occupancy group:
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfim MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
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 Business License BUILDING