06030081 (2)11
17
CITY OF CUPERTINO
n'e' «*�>?''•* zx e '"% ''
BUILDING DIVISION PERMIT
TRACT0RjNF0RMATI0 "e
BUILDING ADDRESS:
PERMIT N0.
AIR QUALITY HEA
06030081
OQ4M6*E:KIRWIN LA
PERMIT ISSUE DATE
^'ONE: M
4 NORTHRUP 3T
SANITARY NO3 1 LNO.
—
BUILDING PERMIT INFOBLDG
ELECT PLUMB MECH
ILImLaa
LICENSED CONTRACTOR'S DECLARATIONJob
Descri tion
1 hembyaffirm Ihl l am Iimmed under provisoes of Chapter 9 (commeaing
PSection
70110) ofDivision 3 ofNe Business and Profeulnm CodamidmyliceneblformandeO�
O
dOi4/3�I%
cgs per
REPLACE FURNACE 60K BTU
ARCHIIECrSDECLARATION
1 understand my plans still be used As Public memds
Licensed Pmfeavional
OWNER -BUILDER DECLARATION
1 hereby aRrm that I am exempt from tho Commctor's License law for the
following moans. (Seerion 703 1.5, Business and Profession, Code: Any city or county
which requires a Permit to construct, alter. Improve. demalim, or repair any structure
Prim m in, issuance. also require, IM applicant for such Permit to Glc A signed statement
Sq. Ft. Floor Area
Valuati
Out he is limned pursuant In the provisions of the CmarearmS License Law (Chspter9
(commencing with Section 700D) of Dlviden 3 of the Business and Prafmdmm Cat) m
that M Y eempl &=from and de basis far the alleged exrmpdoa Any viotadon of
ppN
3 b�t
Occu ane
Occupancy �YPe
S=fm 70115 by arty applicant far a permit wkimu de applim c to a ri l pmlty of
.m mom than nw hundred dollars (tate).
3 5 9 2 0 0.
❑ 1, As owner of Ne properly, ar my emPro,= with wages As deb sole mmpensolm.
Required Inspections
will do the work and the structure isnot Intended an offered for We (Sec. 70M, Businms
And ProfaWOm Cade: The Contractor's License Law dos not apply In An owls f of
property who build, or improves thereon, and who doeuuch wart hlmself ar thro ugh his
Own employee, Provided that Such Improvemenls sort notimended oraaered forme, If,
however, the building or improvement is old within oro year of completion. the owner.
builder will have the burden of pmving dust a did AN build or improve far purpose of
YIc.).
a
❑ 1, u rower of the Property.A. sue s cefessiong with flamed carmuactm a
[3 1, As r of Use
See. 70Y•
(See. Business and Profession Code:) TO Conuacm Lb
the AM
FI�I,�q,LED
are law does not Apply m Su owner of property who build, or Improves dereon, and,
who mnmcu for such projects with acontracher(s) licensed pennant to the Conuacau'A
License Law.
❑ 1 am exempt under See. . B & P C far this reason
�j / C '
APR
Al F' �a� ZOOU
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 Moody, air= under Penalty of perjury oa of the following deHandaruc
BUIL
hve and will maintain A CemlOmte or Camara a AAI WAAure far WoftesCompen-
NG
n, u provided far by Sado. 3700 of dea Luba Cade. rar Ne performancea the
I for which this permit is issued.-
_
❑ 1 haw and will maintain Worker's Compensation insurance, u required by Section-
370Dofthe labor Cado.forthe performuee afthework farwhich this permit ishomt.
Myrier: Cof'ftA an loosens¢caviar and Pol' bumM�� q/
caller. ryr.tor y5 CnyniHga d�3
CERTIFICATE OF EXEMPTION FROM WOR R5
'^et -
`-- m Il("Jfl tPjJ
COMPENSATION INSURANCE
('rhaseetim need nor becompleed If t e permit H faoachundred dollars (g100)
or leu.)
1 cenify that in the performance a the work fm which this Permit is luued, I Nell not
employ any person in my marmncrm As in become subject t0 the, Worgem' L'ompa mallan
Law, of Califomic Date
Applicant
NOTICE TO APPLICANT: If. After making this Certificate of Exemption, you should
become subject to the Workers Compensation powidom of enc lobar Code, you mum
forthwith comply with such prnvis mn, Or this permit tall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby anion that tart B a con,vuctimn tending agency for the perfarmSuce of
Um work for which this permit is issued (Sec. 3097, Civ, C.)
Lender's Nato
Lemderi Address
I cenify that 1 haw read this application And Sure that the above information is
mrrocL I Agra to comply with All city And county onfimances and sure laws relating 10
building construction, end hereby Authmrie mpresenutiw, of this city to enter upnn Be
above-mentioned property fm impaction purpaes.
IWc) agree to ave, Indemnify And kap hrmlrn the City of Carper imo against
liabilities, judgments, cretatad a Kpcosa which may in my way accmc against aid City
In consegance per the g==rog of this porma
APPLICANT UNDERSTANDS AND WILL COMPLY WITH A NON- INT
Issued by:9 Date 's— `
SOU CE REG ATIONS. �
3//S ��
i4cJnO11&f 11
Re -roofs
Type of Roof
Silmaumof Appleanmctar Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant Or future building occuPentmom Or handle hurdoes material
as defined by use Cupertino Municipal Code. ChPter 9.11. And the Health and Safely
Cade, SeNon 25531(.)7
All roofs shall be inspected prior to an roofing material being Installed.
P P Y B
Dy" 9ge ..
r
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use cyulpmem per devices which
heram... air contamimamu As defined by the Bay Area Air Quality Management
all new materials for inspection.
f ❑Ycv
I haw mad to ha)ardoo. material, mqulmments under L'hapw 6.95 of the Callfor.
ni, Health & SafelyCet, Salons 15505.25533 and 255311 underswd that if the building
does not currently have A temnt. that It u my woonathilily m Amory the oceupena of the
mimt�mmener hmum iemel ormiamneeofaCadne, (ice y
Signature of Applicant Date
11'tfet GtaQi� amO 21 " h
All roof coverings to be Class "B" or better
Owner _D¢
or,mho red agent
CITY OF CUPERTINO
if 1 of 1 PERMIT RECEIPT OPERATOR: bethe
COPY # : 3
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 35923013.00
DATE ISSUED.......: 03/15/2006
RECEIPT #.........: 33576
REFERENCE ID # ...: 06030081
SITE ADDRESS .....: 20564 KIRWIN LA
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: MARSHALL CHARLSIE M
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-4317
RECEIVED FROM ....:
AIR QUALITY HEATING
CONTRACTOR .......:
MATTHEW FARBER LIC # 22791
COMPANY ..........:
AIR QUALITY HEATING & AIRCON
ADDRESS ..........:
714 NORTHRUP ST
CITY/STATE/ZIP ...:
SAN JOSE, CA 95128
TELEPHONE ........:
(408)293-7138
&E ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL
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
BSEISMICRE VALUATION 4,355.00
0.50
0.00
0.50
0.00
PPERMITFEE FLAT RATE
1.00
38.37
0.00
38.37
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
----------
164.78
----------
0.00
---------- ----------
164.78
0.00
METHOD OF PAYMENT AMOUNT
NUMBER
----------------- ------------
CHECK 164.78
------------------
52167'
TOTAL RECEIPT 164.78
VOICE ID DESCRIPTION
________
VOICE ID
DESCRIPTION
____________________________
________ ____________________________
301 ROUGH PLUMBING
303
ROUGH
MECHANICAL.;
304 ROUGH ELECTRICAL
505
FINAL
ELECTRICAL
507 FINAL PLUMBING
508
FINAL
MECHANICAL
10
•
0
Community Development
10300 Tone Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
JOB ADDRESS:
O s n La
PERMIT #
0 01030e
OWNER'S NAME: s'
PHONE # 416 —71 $
GENERAL CONTRACTOR or 1,+U
FAX # 4oec� D $
t
I am not using any subcontractors: "Q 3// O%y,
Signature Date
Please check applicable subcontractors and complete the following information:
Owner/Contra—d6 Signature
3/as o
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
41y.(a
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/Contra—d6 Signature
3/as o
Date
r( .
1'117 f/i
CUPEIiTINO
CITY OF CUPERTINO
PERMIT APPLICATION FORM �IP03(ib I
APN #
352-,23-0/3
Date:
Building Address:
BUILDING
0S6 'r w i 2
BREMFURN
Owner's Name:
Phone #:
Cv\a eLI
q 09 -asS -�fS
Contractor:
License #:
A-; r,.x. tu
BREMAIRHAN
Contact: ICupertino
Business License #:
�r
BREMRECEPT
Building Permit Info:
ELECTRICAL
Bldg ❑ Elect Plumb ❑
Mech.
Job Description:
BUILDING
VIA
EPERMITFEE
Residential 54 Commercial M
ELECTRICAL
For Residential Installations:
MPERMITFEE
Attic ❑ 151 floor 2�" 2"d floor ❑
MECHANICAL
Adhere to min set back requirement ❑
PPERMITFEE
For Commercial Installations:
PLUMBING
Replacement same weight ❑ Additional weight (structural talcs) ❑
BPERMFEE
Structural Calculations required for new installation ❑
BUILDING
New installation Planning Approval Required
BPLANCHK
Cost�f Project: Type of Construction:
Occupancy group:
o+ C2 J
(- s
Strapped LJ On Platform 0 Bonded 0
Sq.Ft. Floor Area:
New Location ❑ Replacement ia
Qty. if
P.N In
Fee De-Rcrintion
Fee GrouD
BENERGY
Energy
BUILDING
BREMFURN
Relocation of Furnace
MECHANICAL
BREMACOVER
A/C Unit> 10,000 cfm
MECHANICAL
BREMAIRHAN
A/C Units <= 10, 000 cfm
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