06080108 (2) CITY OF CUPERTINO �
BUILDING DIVISION PER VC0NTRACTR�IONFORMATION
�`9E�auYe
BUILDINGADDRESS: s A PERFECT CLIMATE PERMIT NO.
21538 ROSARIO AV
OWNER'S NAME: PERMRISEUEDATE
URBAN EDGAR 10570 S DE
NE: SANITARY N0. CONTROL NO.
(408) 86119545
ARCHITECnENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
too LICENSED CONTRACTOR'S DECLARATION
a 1 hereby amsm Nat T an licensed under provisions of Chapter 9(commencing Job Description
ISE with Section 7Mt))of Division 3 o the Business and Professions Code.and my license is
N in full fares and effect Z � ADD A/C TO HOME
ense
LicClau Lk.g
•Fo
Dam Contractor P
ARCHrili DECLARATION
i W V I undersand msh
y ph. all W useas public public records
°Q� Licensed Professional
3 OWNER-BUILDER DECLARATION
if1 hereby affirm Nat I am exempt from the Condamah Lmmm Law for the
C o following reason.(Section 7031.5,Business and Pmfersions Cads:Any city or county
which mquires a Permit to construct.alter.improve,dcmoinda,or repair any structure 517
prior m its issumme,also requires the applicant for such permit w file a signed statement
:xWtMllicensedpessort,totWProvisionsofthcContrxmisUse.Law(Chapter9 Sq.Ft.Floor Area Valuation
Z.a (commencing with Session 7000)ofDivision 3 of the Business and Pmfcssiom Code)or
that he is exempt therefrom and the basis for the alleged mmnption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of r Occupancy Type
not mom than five hundred dollars(5500).
❑I.as owner of Ne property,or my employees;with wages m their sole compenssdon,
will dothewas,Chum Th Cont Is riots Liceesm Lan us Tonle(See.7014,Business
and property
au Chun:The met tracmfs License Law dao ria apply lf an owner or Required Inspections
Own eny who employees.provrimpmt at such
h improvements,
and who arm On intended hwdk himffered hmugh his
awnver.thWilding
improvement
sincon arofor mplcu offered owner- '
seda.If.
however,the building or improvement u hath within arc Wild of Improv far thepme,of
builder will have dm burdert of proving that he did trot build a improve tar puma.¢of
sok.). r
El 1,d owner of Ne i mpert,am emlusively contracting with licensed eman ma s in
construct the project(Sec 7044,Business and Pm(csslom Cade:)The Comma ser s W-
e Law does not apply he an owner of progeny who builds or improve drt
mnn,and
who
who contracts far such pmjccu with a cantauwr(q licensed punuam he use Contrumr's
License taw.
❑Imp eaemDt undo Sec ,B d P C(or this rtsson
Owner Dare i
WORKER'S COMPENSATION DECLARATION
I hereby a1ffmat under penalty of perjury,one of dm following dalerdiam: L �/
1 haw and will maintain a CeniBam of Consent in self-insum fa Wmkcr's Camper.
sdion,as provided for by Semon 37M of rhe Labor Code,far Ne part....or the V
work far which this permit u issued.
❑ 1 have and will maintain Waker's Compensation Insurance,as required by Section
3700 of dm tabor Code,for the peif.m u tt of the work for which Nis permit is issued.
My worinae c I lmunuu tinier and Policy murk,are:
Came,.. .H-I� N s P°licy NJ sT'`(&— ��G "3 0?o So d
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
into xtti.need Mt W completed if the permit is loran.hundred dollars(SIM)
loss.)
I ccnify that in the peifamencc of the work for which this permit is issued.I shall at
employ any person in any manner an d m become subjectto the Worheri Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Warker's Comp naa non provisions of the Labor Code,you am
.,O foMwith comply with such provisions a t m
this Permit W deemed mvmked.
E ^' CONSTRUCTION LENDING AGENCY
E~ .�. 1 hereby air,.Nat thea I,.comuuctinn lending agency for the perfurtnana of
!Ythe work for which this Permit is issued(Sac.3097,Civ.C.)
�W~n- Lender's Name
C z Lender's Address
V O 1 certify that I haw read Nis application and them that the above information u
ly
cam".1 agree m comply with all city and county ordinances and sum laws misting to
Q U Wilding construction.and hereby autharimmyresenanives of Nis city to enter upon the
ra move mentioned PMNrLy for inspection purposes.
(We)agree m save,indemnify and keep bumless the City of Cupertino against
rF-t h liabilities,judgments,costs and expemm which may in any way acerae against said City
U Z in consequence of Ne Standing of this Permit.
r—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 67
SOUR REGULATION , -
D / "�6 Re-roofs
Slgndurt a(Appli H CAYARDOUS MATERIALS DISCLOSURE Dam Type of Roof
Will the applieent or faun Wilding oaupant sart"handie hrrardous material
u defined by the Cupertino Municipal Code.Oupmr 9.12.and the Health and Safety
Cale.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
40 0Yer 1pam
Will the applicant or forum building Occupant tax equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hozarmur air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Ye N°
1 have mad Ne havmduu materials require..under Chafer 6.95 of the Calif.,
his Health k SafmyCodc,Satiate 25505.25533 and 25534.1 undersun!thm irthe Wilding
doer fro eurrtn0y M.e a tenant Nd it is my rtspomihility m rwtify the oavpmu of dre
req°innaIn It an tp °�° a"fAj"rdr"'m°r° "prosy. Signature of Applicant Date
Sj/-- 6 All roof coverings to be Class "B" or better
owner or authorised ahem pate' g
CITY OF CUPERTINO
!m 2 of 2 PERMIT RECEIPT OPERATOR: Zmyw
COPY #Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35619023 . 00
DATE ISSUED. . . . . . . : 08/16/2006
RECEIPT # . . . . . . . . . : 35641
REFERENCE ID # . . . : 06080108
SITE ADDRESS . . . . . : 21538 ROSARIO AV
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER URBAN EDGAR
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : A PERFECT CLIMATE
CONTRACTOR . . . . . . . : SMITH, BYRON E LIC # 21144
COMPANY A PERFECT CLIMATE
ADDRESS 10570 S DEANZA BLVD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . . : (408) 86119545
•FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- - --------- ---------- ----------
BREMAIRHAN NO.UNITS 1 . 00 10 . 26 0 . 00 10 . 26 0 . 00
BREMRECEPT NO. OUTLETS 1 . 00 1 . 20 0 . 00 1 . 20 0 . 00
BENERGY PERMIT FEE 1 . 00 34 . 86 0 . 00 34 . 86 0 . 00
BSEISMICRE VALUATION 5 , 170 . 00 0 . 60 0 . 00 0 . 60 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 162 . 03 0 . 00 162 . 03 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
- - - -------------- ------------ -------- ----------
CHECK 323 . 96 025241
TOTAL RECEIPT 323 . 96
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL 508 FINAL MECHANICAL
•
/ Community Development
!4114
130 Torre Avenue
Cap Oertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
IOUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
N060(06
OWNER'S NAME: c( ac (,{cbu r PHONE #
GENERAL CONTRACTOR ec ec+ C l ✓via 2 FAX # /OC-- p6 /- cjS y
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followin information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
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/Contractor Signature Date
CITY OF CUPERTINO 0U()8oI Qpj
' FURNACE/AC
OPUPEkTINO PERMIT APPLICATION FORM
APN # OJ_ Date: I I ^ �^
Building Address: Lop
1 �--6 ZOsac , o Ay
OwneF's Name: Phone #:
�l �, Qc ba 0K- 5-7-I 3�s
Contra�t\or: Phone: License #:
e� � ec/4 ,VnaIe- Vog -90, 95`1.5 -73315�'-
Cont ct: Phone: Cu ertino B iness License#:
/Q�-� l- 9sys lly
Building Permit Info:
Bldg ❑ Elect Plumb Mech .0_
Job Description: a I n 0�1C �
0(�,fl �
Residential Commercial ❑
For Residential Installations:
Attic ❑ I" floor ❑ 2nd floor❑
Adhere to min set back requirement
or Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Costlif Project: 3 Type of,Cpnstruction: Occupancy group:
Strapped El 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
I BREMAIRHAN A/C Units<= 10, 000 cfm MECHANICAL
BREMRECEPT Recptl, Switch & Outlets ELECTRICAL
1 BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
I EPERMItFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
I PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BPGAS Gas Piping System Fee PLUMBING
BUSLIC Business License BUILDING