05010029 (2) CITY OF CUPERTINO x-
BUILDING DIVISION PI✓RMIT CONTRACTOR�INFORMATION
"d.aA �G `ea r
BuIDIN'ADDRESS: RESIDENTIAL HEATING AND A/(T'TfTD'05010029
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
18 Cp LICENSED CONTRA CTO 'SD LARATION
IWrcbY firm Nal l Labb sed 111CI
mna,(chapltry(mmmtnring Job Description
5Zw with n Bar.whion3ofthe BurofessionsCode.andmyliccnscis
d cif�.�` rS �-I REPLACE FURNACE
noI .Y —SION�J' �or UI antler WKd my plans shall he useo eofdf ,J nISK
o Licensed Pmfcui...I /s✓l�
5 OWNER-BUILDER DECLARATION V
2 s S 1 hereby at0rre that I am exempt from the Contractor's License Law for the
O O following reason.(Section 7031.5,Business and Professions Calc:Any city or minty
�m which mottoes A pctmit tit construct,alter,improve,demolixh,or repair any structure
zi prior m its issuance,also requires the applicant for such permit to file aMilood statement
cma0 that he is licensed pursuant othe pmvicimuof the Contractor's LimnuLaw Charter Y Sq.Ft. Floor Area Valuation
(commencing with Scmlon70(lo)of Division 3 aftW Basin.and Prussic.,Cede)or
i that he is cacmpl mcefrom and the buts for the alleged cscmption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil prosily of 3"N31bfi9eJ 0 0 Occupancy Type
not more than five hundred dollars(SSW).
❑I,a owner of the propscely,or my employers with wages as Meir sale compensation,
will do the work and me swctom is not intended or offered for sale(Sec.7W.Business
and Professions Code:The Contractors License Law dors not apply to an owner of Required Inspections
property who builds or improves thereon.and who does such work himself or through his
awn employees,provided that such improvements are not intended or offered for sale.If,
however,me building or improvement is sold within one year of completion,Our owner-
builder will have she burden of proving that he did not build or improve for purpose or
salt.).
❑1,as carer of the propeny,am eaeluaively contracting with E.eneed contractors to
constrict the project(Sec.70an.Business and Profusions Code:)The Contractor's Li.
reac law does not apply to an owner of proper who Wilds or improves document,and s
who contracts for such projects with a con ra Lor(s)licenxd pursuant o the Contractor's
License Law.
El I em cacmpl under Sec. .B k P C for this rcazon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one Lithe following declarations:
I have and will maintain a CcWifeate of Canunue xlf-insure for Workeri Cumpcm
.Lion,u provided for by Section 3700 of me labor Code,for the performance of the
work far which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,u requited by Section
3700 of the Labor Cade,for me performance of me work for which this permit is issued.
My Worker's Cnmpensalien losunnce canicr mJ Polity numbcraOQ
Carrier: )) 'Ct— (l0� Policy
CERTIFICATEOFEX PTIONRtO ORKERS'
COMPENSATION INSU CE
nbis section need not W completed if the permit is for one hundred dollars SIOO)
or less,)
I..Wiry dust In the perfarmance of the work(a,which this permit IS issued,1 shall nut
employ any person in any manner so as to become subject a the Workers'Compensation -
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Cenifieale of Esemption,you should
become subject to the Worker's Cam ECosalion provislans of the Labor Cast,you most
z forthwith comply with such provisions or this peroul shall be deemed r.vnked.
z O CONSTRUCTION LENDING AGENCY
1 Wrchy affirm that mere is a cmtswctinn lending agency far the performance of
Yd ? the walk far which this permit is issued(Sec.3841,Civ.C.)
13 Q Under's Name
z Lender's Address _
J O 1 Ceniry that 1 have read this application and state Thal Our above information is
y P .omen.I Agree to Comply aim all city and county oNinaruxs and sure laws misting to
0 U Wilding construction,and hereby aumodre mrassenulivu or oris city to enter upon ft
W .hove-mentioned property far inspection morasses.
(We)agreesave,indcntmfyandkith ayinan me city or CupcnstSageing
(n
liabilities,(We)gretosasu andrualfy and keep mayins,the
y way riCupertilseldCity
J z in consequence of the granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-P INT Issued by: Date
SOUR REGULATIONS.
1 'u Re-roofs
gnaw.of Applor Cunlraaor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or
future building occupant store or M1andlc hararduus material
u defined by the Capetian,Municipal Cod.Chapter 9.12.and tM Health and Safely
Code.Sc.Oen zss3z(a)7 All roofs shall be inspected prior to an roofing material being
❑Yea Na P P Y g g installed.
Will ter applicant ar�wtrm building occupant sex equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
ha'sardous air Contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
rstrict7
Fl year NO
I have mad the haaardous materials reyuirimcnu under Chapter 6.95 of the Califor. ,
nice Health K safety Code,Sections 25505,25533 and 25534.1 undrsund the if the Wilding
docs not emenay have a tenant,that it is my responsi hility to mad the Occupant of the
myuircm gwhichmustheracyortoissu erpraCemr teofDcction.y Signat ore of Applicant Date
Sv
nerafaamaa,<aaprnt Date All roof coverings to be Class"B" or better
CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 35923013 .00
DATE ISSUED. . . . . . . : 01/05/2005
RECEIPT #. . . . . . . . . : 28177
REFERENCE ID # . . . : 05010029
SITE ADDRESS . . . . . : 20564 KIRWIN LA
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CHARLSIE MARSHALL
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4317
RECEIVED FROM . . . . : RESIDENTIAL HEATING
CONTRACTOR . . . . . . . : DOMINGUEZ, OCTAVIANO LIC # 21161
COMPANY . . . . . . . . . . : RESIDENTIAL HEATING AND A/C IN
ADDRESS . . . . . . . . . . : 65 CRISTICH LN
CITY/STATE/ZIP . . . : CAMPBELL, CA 95008
TELEPHONE . . . . . . . . : 4083774073
4E ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW HAL
BREMFURN NO UNIT 1.00 14 .31 0.00 14 .31 0.00
BENERGY PERMIT FEE 1.00 34 .86 0.00 34 .86 0.00
BREMRECEPT NO. OUTLETS 1.00 1.20 0.00 1.20 0.00
MPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
BSEISMICRE VALUATION 1,852.00 0.50 0.00 0.50 0.00
EPERMITFEE FLAT RATE 1.00 38 .37 0.00 38.37 0.00
TOTAL PERMIT 127.61 0.00 127.61 0.00
METHOD OF PAYMENT AMOUNT NUMBER
__________________
CHECK 127.61 19759
TOTAL RECEIPT 127.61
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
SrUPERTINO PERMIT APPLICATION FORM D 56106d /
APN # Date:
Building Address:
Owner's Name: Phone#:
ar10la655
ontractor: �P�hone: License#:
c. 3`ln- �10-13
Contact: Phone: Cupertino Business License #:
1N 81�n 31-1 - x-1013 02 � � b
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description:
Residential '® Commercial ❑
For Residential I t Mations:
Attic 11l't floor 2nd floor❑
dhere to min set back re uirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Lkpproval Required ❑
Cost of Projec Type of Construe i Occupancy o
i�sa. oo 4v Ac
Strapped ❑ On Platform ❑ Bonded ❑ Sq. t. Floor Area:
New Location ❑ Re lacement
QtY .f
A is ble Fee ID Fee Description Fee Group
BENERGY Ener BUILDING
BREMFURN Relocation of Furnace MECHANICAL
M
BREACOVER A/C Unit> 10,000 cfln MECHANICAL
BgEMAIRHAN A/C Units <= 16-,-000 cfm MECHANICAL
BREMIZECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
_ BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
Qt
Plumbing Permit Issue PLUMBING
BPERMFEE
Bldg Permit Fees BUILDING'
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING