06030180 (2) CITY OF CUPERTINO R
BUILDING DIVISION PERMIT �hCONTRACTQR INFORMATION <.
BUILDING ADDRESS: O.
22406 RANCHO VENTURA ST
R'S NAME: PERMIT ISSUE DATE
WEBSTER DAVID A 1712 STONE; AVE 03/31/2006
PHONE: SANITARY NO. CONTROL N0.
(408) 293-4717
ARCHITECTYENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
±op LICENSED CONTRACTOR'S DECLARATION Job O
ZC 1 hereby affirm that 1 am lionnsed under provisions of Chapter 9(commencing g
<b wiNSttuon70IXryafDivision3ofNc8usincvsandPmfessionsCodc.andmyliccnmis REPLACE 60, 000 BTU F ��®
nen.m in full farce and c fig . ,
y z Licc r.Cloy s Lic.tl -
f Date S- Contramor -
g ARCHITECTS DECLAR ON GC uu
Sr m a I undcraund my plans shall W used as public records APR �y ajooaa
,o' g_ L o
G
� Licensed Professionm
S OWNER-BUILDER DECLARATION
ii 1 thereby affirm that I am exempt from Ne Contractors License Law for the
00 following mann.(Section 1031.5,Business and Proressions Code:Any city or county 2000
<$E. which requires•permit to construct.alw,improve,dcmollsh,or repan any swemrt ILDINW,
yZ'a prior m its issuance,also requires the applicant for such permit to file a signed statement
EEs< that he is licensed pursuammshe proviaionsoflhcContractor's Leon.Law(Chapter 9 Sq. Ft. Floor Area ValTation
Y�$ (commencing with Section 7000)of Division 3 of the Business and Praressinns Cads)or
Nor he 6 exempt thme(rom and the hula for the alleged exemption.Any violation of
Section 7031.5 by any applicant far a permit subjects the applicant to a civil penally of um er Occupancy Type
not more Nan five hundred dollars(SAID).
❑I.as comm,of the property,or my employees with wages ax their able compcnssdon,
will do the work,end Ncswcwa isnot intended or o@nxi for age(Sec.7044,Business Required Inspections
and Prefesaions Code:The Conlncmors Int
rs License law dl apply to an owner of q P
property who builds or improves thereon.and who docs such work himself or through his
awn employers,provided thatsuch improvements tie not intended mattered fmssla It.
however.the building or improvement is sold within oro year of compleuon,the owner
builder wilt have the harden of proving that he did not Wild or improve for purpose of
sale.).
EI 1,as owner of the property.am exclusively contracting with licensed conwmora to
construct the pm*t(Sec.7044,Business and Prefessioos Cade)The Contractors Li-
come law docs not apply to an owner or property who Wilds or improves thereon,and. "
who convects for such projects with a conuacmr(s)licensed pursuant on the Contractors
Licenx law.
❑I am exempt under Sec. B k P C for this mason
r Data
WORKER'S COMPENSATION DECLARATION
T herebj affr n under penalty of perjury me of the following declarations:
❑1 have and will maintain a Certificate ofConsent m.aelf-insure far Worker's Comma.
sauon,as provided for by Section 37M of she Labor Cade,far the performm ec of the
weak for which this permit is reduce. s
❑1 have and will maintain Workers Compensation Insurance.as required by Section
3700of the labor Cade,for the performance of the work for which this permit is issued.
My Worker's ACompensationrhasonm,carrier and Policy number are: i
Cartier: J'tn y'e Gage Policy No.:'7/ fi
C�RTiFl—1 OF EKEMP ION FROM W WORKERS
COMPENSATION INSURANCE
(rhis sesrian need not beeomplmed if Ne permit is foram hundred dollars(SIM)
or less.)
I ceruf-v that in the performance of tW work for which this Permit is issued.l shall not
employ,any person in any manner an as w become subject o the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,afar making this Certificate of Exemption,you should
become subjca to the Worker's CoMmundi al provisions of the Labor Cade,you must
w,O foMwith comply with such provisions or Nu Permit mail W deemed revokd
e
ZN CONSTRUCTION LENDING AGENCY
[-� Ihereby afllrm that Nem is a construcunn lending agency far the perform.of
C' Ne work for which this permit is issued(Sec.3(197,Ci,C.)
W�A Lender's Name
= 2 Lenders Address
U O 1 eeAfy that 1 have read this application and state that the above information ix
It, correct.I agree to comply with all city and county ordinances and smc laws bding to
�U Wildingconsraction,and hereby autborim representatives of Nis city to enter u,mobc
[St move-mcmionmems.ed c sit for
aninspectioneeea purposes.
la� (We)eg¢c to save,indemnify and keep harmlass the City of Cupertino against
TZ incoiuesuenct, fthegrantingng of this..which may in anY war accrue against said City
Uz Aconsequence of UNDERSTANDS
NisDWI '�jT`C
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date .�
SOU EREGULATIONS.
—s4to�Re-roofs
ignmure of Applicam/Comm, Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupantstom or handle hasardous material
dcfrncd by do Cupertino Municipal Cade.Chapter 9.12,and the Heahh and Safety
e.Duan 25532(1)? , All roofs shall be inspected prior to any roofing material being installed.
Ye
will thea Bcaul or rntbre Wildin «c, of use, If a roof is installed without first obtainingan inspection,I agree to remove
pp g N equipment it devices which P
emit harardnus air contaminants az defined by the Bay Area Air Quality Manegcmcm all new materials for inspection.
Dixtrin?
QYcs /[$\'No
Ihavemad Nelwanxi ustTalcrialsrequimmcnuunderChapvsG95rflhcCalifor-
nla HeslN6SmclyCbde.Sttfi.25505.25533and25534.Tundersmnd Nmifthe Wilding
does not currently hare a tenant,that it is my responsihility m notify Nc occupant or the
reetf�., J9'�gnuwhich must
a�es or,uNomcJ agent Wm�LL,dd.l to iissusn¢ofa Certificate of Occpanry.
Signature Of Applicant Dale
a 4fo�1? - --- iJ ; All roof coverings to be Class "B"or better
npas
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
WCl OF Fax(408) 777-3333
kT
Building Department
JOB ADDRESS: PERMIT #
c W,0 PZ;U7-�l-A W 60--?6/4-0
OWNER'S NAME: o ><r.,�,/t PHONE #
GENERAL CONTRACTOR: o o>� e FAX #
I am not using any subcontractors: 61
Signature ate
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 A Do�00A !1/7C
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
I* 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35703019 . 00
DATE ISSUED. . . . . . . : 03/31/2006
RECEIPT # • • . . . . . . . : 33808
REFERENCE ID # . . . : 06030180
SITE ADDRESS . . . . . : 22406 RANCHO VENTURA ST
SUBDIVISION . . . . . . :
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER WEBSTER DAVID A
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : NASHVILLE TN, 37202-2131
RECEIVED FROM . . . . : JIM RANDO
CONTRACTOR RANDO, JIM LIC # 8050
COMPANY . . . . . . . . . . : AAA FURNACE & AIR CONDITIONING
ADDRESS . . . . . . . . . . : 1712 STONE AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
• TELEPHONE . . . . . . . . : (408) 293-4717
FEE 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 2, 000 . 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
----------------- ------------ ------------------
OTHER 164 . 78 VISA
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
•
CITY OF CUPERTINO ObU30I�0
FURNACE/AC
•CUPERTINO PERMIT APPLICATION FORM
APN# 3�1 0� DI� Date:
J
Building Address: n
C c W0
Owner's Name: Phone#:
—=W-b 0/-
Contractor: License#:
Contact: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect e Plumb Mech
Job Description: �
G� ADO I`JTU -)[014a c
Residential d:. Commercial ❑
For Residential Inst llations:
Attic ❑ 1" floor 2"d floor❑
41Adhere to min set back requirement❑
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: Occupancy group:
.-jx',pe,C.0 U 2—
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
A licable Fee ID Fee Descri tion Fee Group
BENERGY Energy BUILDING
BREMFURN 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