07080040 CITE'OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDIt�clR><ss:TUGGLE AVE AAA F JRNAC E & AIR PER IT NO.
07080040
OWNER'S�NjA�jME; r P I ONING PERMTT ISSUE DATE
LAWRENCE LARSON 1712 STONE AVE
E: SAMA O. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
REPLACE FURNITURE BLDG ELECT PLUMB MECH
C7 O O D
z LICENSED CONTRACTOR'S DECLARATION
o Job Description
F. I hereby affirm that I am licensed under provisions of Chapter 9(commencing
U with Section 7000)of Division 3 of the Business and Professions Code,and my license is
�• in full force and�i ff ti
z License Class I Lit:q7119 7
p
Date
Contractor
ARCHITECTS DECLARAMIN
I understand my plans shall he used as public records
U
F' Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
o following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct•alter,improve,demolish•or repair any structure
y prior to its issuance,also requires the applicant for such permit to rile a signed statement
o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
o (commencing with Section 7000)of Division 3 of the Business and Professions Codc)or
^° that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than rive hundred dollars($500).
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work.and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of (1 p
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The ConuactGes Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
❑I am exempt under Sec B&P C for this reason
Owner Date .
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of pedury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers CompensationI�r.�surance carrier and Policy number are:
Cartier. I 7fQ /'zi: ie/ Policy No.N t
C OF EMPTION FRO O C S'
COMPENSA17ON INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I cenif-v that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption•you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
O forthwith comply with such provisions or this permit shall be deemed revoked-
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C-)
a Q Lender's Name
Z Lender's Address
0 1 certify that 1 have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating to
building construction,and hereby authorize representatives of this city to enter upon the
C>a ahove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
y r/) liabilities,judgments,costs and expenses which may in any way accrue against said City
,Z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: .��
SO CE REGULATIONS.
Re-roofs
ignature o A icon on or bate
HAZARDOUS MATERIALS DISCLOSURE Type of Loof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
[3 Yes "
Will the applicant or acture building occupant use equipment or devices which If a roof's installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes �No
I have read the hazard materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.t understand that if the building
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
require enLs which must be met prior to issuance of a Certificate of Occupancy.. Signature of Applicant Date
All roof coverings to be Class"B" or better
Owncr or authorized a ent c
CITY OF CUPERTINO
6 ITEMS OF 14 PERM-".T RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Bl.k: Lot:
APN . . . . . . . . : 3"534045 . 00
DATE ISSUED. . . . . . . : OE�/06/2007
RECEIPT #. . . . . . . . . : BS000002269
REFERENCE ID # . . . : 0"'080040
SITE ADDRESS . . . . . : 1E930 TUGGLE AVE
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER LF.WRENCE LARSON
ADDRESS 1E930 TUGGLE AVE
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : JIM RANDO
CONTRACTOR . . . . . . . : RFNDO, JIM LIC # 8050
COMPANY ATA FURNACE & AIR CONDITIONING
ADDRESS 1i12 STONE AVE
CITY/STATE/ZIP . . . : STN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408) 293-4717
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BENERGY PERMIT FEE 1. 00 34 . 86 0 . 00 34 . 86 0 . 00
BREMFURN NO UNIT 1. 00 14 .31 0 . 00 14 .31 0 . 00
BSEISMICRE VALUATION 2, 200 . 00 0 .50 0. 00 0.50 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
PPERMITFEE 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 REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 341 . 52 VISA
---------------
TOTAL RECEIPT 341 .52
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 070JP 0-054d
am ACEI AC
CUPEi�TINO PERMIT APPLICATION FORM
CPN Date: �G ✓��-�J..�� y CJ U r
Building Address: _
D 2l
Owner's Name: Phone #:
Contractor: Prone: License#:
V-J fl 217
21
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect Plumb [1--' Mech
Job Description.
c -
Residentia Commercial ❑
For Residential Installations:
Attic ❑ 1St floor P 2nd floor❑
Adhere 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:
'I 2- o -`3
Strapped ❑ On Platform M- Bonded Sq.Ft. Floor Area:
New Location Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER J�-/C Unit> 10,000 cfm MECHANICAL
BREMAIR14AN AX Units<= 10, 000 cfm MECHANICAL
BREMRECEPT P ec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
f EPERMITFEE l;lec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
/ PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Ilan Check Fee BUILDING
BPGAS (Jas Piping System Fee PLUMBING
BUSLIC Business License BUILDING