08100135 CITY OF CUPERTINO «sx,a;ta";•' `? '-"
BUILDING DIVISION PERMIT C�EzalI'RAGTOR$INk'ORMAT�ION
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: PERMrf ISSUE DATE
A O. CONTROL NO.
IN
(650) 321-5500
ARCHRECU/ENGINEER: BUILDING PERMIT INFO
BLDG EIEGI' PLUMB MECH
00 LICENSED CONTRACTOR'S DECLARATION
U 1 hereby aRnn that I.m Iismed under po limas of Chapter B(commeadng lob Description
W wish Section 7o1f0)of Division 3afdm Buainw and Profcav yliccocu
.ML in haat mane and d ADD NEW A/C (OUST IS ADDING ADDITIONAL AC)
3 g Z Limentc Clan[��y��--�Lk.g
t Date p/ RECTSn
ARCN DECLARATION'
e A ATION
undersexed undcund my plans dull be used a public records
e
I Gln Licensed professional
N3 OWNER-BUILDER DECLARATION
i S 1 hereby alarm that I am excmpt from to COmorm rs License Law far 0c.
p O following mason.(Section 7031.5.Business and Professions Code:My city of county
which requires a permit to construes,alar.improve.demolish,or repair any vmerum
_Z< prior o its issuance.also requires the applicant forsuch peruni,in file a signed statement
thatW is licensed purmmm to dm pievisioro of the cnna«mr•waenac Law(Chapter a Sq.Ft.Floor Area Valuation
z�$ (commencing with Section 7000)of Division J of the Business and Professions Cram)or
ay — that has Is seems,theseftom and dm buss for the alleged excmptian Any violation of 0
Section 7031.3 by any applicants f«a permit objects the applicant to a civil penalty of APN Number Occupancy Type
m
no, art Nan five hundred dallus 0$300). p y yp
01.maw« artieuvpny,«mrernvlayee.mthw,gaathc'trmkanpensatian 35911014 . 00
will do the work and thessomum ts ms amended«oRcmd f«sam(Sce.7014.Business
and Pmfeuions Cade:The Comecon.License Law docs rot apply in an owner of Required Inspections
popeny who Wildsarim mince arcon.mil who doessuch work himselforthmugh his
own employers,preevi cd Nat such improvements are not intended oroRcred formic.If,
however,Ne building or impoa.t is sold within arc year of mmplction.tlse own.-
builder will have the burden of pro ing dint his did tot build or improve f«purpose of
sale.).
❑1.as no.of the poperty,w exclusively canumcting with licensed rnnrsa[ors o
construct the project(Sec.7144.Business and Profusions Cade:)The Com ocuir's U.
ccve law docs not apply to for owner of property who Wilds or improves thereon.and
who contracts for such projects with a ucnuamor(s)licensed puuumt to ft Conuacor's ,
License Law.
❑I am exempt under See B B P C for this reason
Own. Dam
WORKERS COMPENSATION DECLARATION
I botchy affirm under persky of perjury,one of the following declarations:
1 have and w01 maintain.CertiGate ofC...t o self insure r«Worthen.Compen-
rion,as povbk4 for by Section 3700 of the labor Cade,f«the performance of the
work for which this permit is isucd.
1 have and will maintain Workers Compensation Innvanm,as requiredi by Section
3700 of the Lab°o�rrCocc.far the performance ofdo work f«which this permit u issuedmy W.,loo, '
Carrier. '/.{/ .and Polity number art:
random lexame
PoI'ay No:`WORKS S'
C FlC COMPENSATION
NFltAN WORKERS'
COMPENSATION INSURANCE
frusseetion need hat W emnplewl lithe pewit is for uchunNed do0a s($100)
M lass)
1 certify that in tine Wrormanca of the work for which this permit u issued.l shall am
employ any person in my mmncro as to become subject tithe Workers'Campcnmtion .
Uwe of California Dao
Applicant
NOTICE TO APPLICANT:If,alley making this Cenifrcata of Exemption,you should
become subject in the Workers Compenation provisions of the Ulcer Code you mut
.,O foMwith comply with such povisions or this permit.hili IN deemed reokcd.
'Z v--' CONSTRucnoN LENDING AGENCY
N
[-+ r 1 thereby which
this Neve Issconsotrc.307,Cint agency for do perfurmenceof
IZ the work(ase whicA Nis permit 4 issued(Sec.J09'i,Civ.CU
W�0 Lenders Name
O z
Lenders Address
V O 1 certify that 1 have read this application W sum that do above information is
IP. context.I agree to comply with all city and county ardinances and sum laws relating in
o Wildingcammction•mtlhcmbyanthorimmpresenufi sat Nucityocnorupnnmc
move-mentioned property for inspection purposes
0. (We)agree to save.indemnify and keep harmless the City of Cupertino against
h liabilitiesjudgments.coast and expenses which may in my way accme against said City
t.1 z APPLLIICC NT UNDE STANDSOND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO REGU ONS. J7
(/ Re-roofs
Sigfxture of ApplicanUCa r Data
x RDOU TERIALSDISCLOSURE Type of Roof
WI111heappliantorfumm riding«cupmtswmorhandkhw oamimrial
a defined by 0c.CuMnim Municipal Code,Chapter q.lr.and bre Health and Safety
Code.Section us]z(a)T
❑Ycs �Na All roofs shall be inspected prior to any roofing material being installed.
Will Ne'it
or fuom building occupant use equipment or dcvicu which If a roof is installed without first obtaining an inspection,I agree to remove
41.1111 It air contaminants ant defined by that Bay Area Air Quality Management all new materials for inspection.
sttictT
❑Yes bNu
Ihave mayce , Ntwsmuerl.n53iremm�u undcrCNpterd.uifNe Calif«- 2iL'sVLv- /I/ r _OV
nu Heal 5 YCade.Secti«u 2350.3,233]]mJ i3536.1undmmntl Nuifthe building
dors c 'nUY have.taant dw it ponsibirty o notify the oeeupmt car the
requi which moat met prima or a Certificate or am Signature of Appl' a Date
tir or authorixed agent Data
1-1/roof coverings to be Class'%r{."or better
CITY OF CUPERTINO
• 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35911014 . 00
DATE ISSUED. . . . . . .. 10/22/2008
RECEIPT # . . . . . . . . . : BS000006426
REFERENCE ID # . . . : 08100135
SITE ADDRESS . . . . . : 20686 RODRIGUES AVE
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : ONER, KARAY
ADDRESS . . . . . . . . . . : 20686 RODRIGUES
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2965
RECEIVED FROM . . . . : JOHN F DAHL PLMBING
CONTRACTOR . . . . . . . : GARY CAVAGNARO LIC # 5573
COMPANY . . . . . . . . . . : DAHL PLUMBING CO, JOHN F
ADDRESS . . . . . . . . . . : P O BOX 450
CITY/STATE/ZIP . . . : PALO ALTO, CA 94301
TELEPHONE . . . . . . . . : (650) 321-5500
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 3 , 200 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 .79 0 . 00
1MPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
IMRRAA UNITS 1 . 00 61 . 19 0 . 00 61 . 19 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
- -------- ----- ----------
TOTAL PERMIT 224 . 85 0 . 00 224 . 85 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------- --------------- --------------------
CHECK 224 . 85 #35530
---------------
TOTAL RECEIPT 224. 85
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- ------ ----------- ---
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
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CITY OF CUPERTINO
_ FURNACE/AC
• CUPEt�TINO PERMIT APPLICATION FORM
APN # Date:
05q f I oI �.
Building Address: ,—j O` I —r
19
Owner's Name: vF-6 0` ^ n / IH 6� . �S S_ V�W,
Contractor
Q„�i J Q Phone
Fax #:'IGSc�
Contractor License #: Cupertino Business License #:
O`p �� S'S q3
Contact: Phonc #: Sp _ T-60
(,CLn, Q ccw Fax
Building Permit Info:
Elect❑ Plumb ❑ Mech
Residential tgCommercial ❑
• Job Description: __
\I`QS — �4 J�hw WG��S V�cJ k
For Residential Installations:
Attic ❑ I" floor ❑ 2°' floor ❑
Adhere to minimum setback requirement
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural talcs) ❑
Structural Calculations required for new installation []
New installation Planning Approval Required ❑
Cost
(o(f Project: Type of Construction (Usage Class):
<` r�;2, O0 - C->8'
Strapped El On Platform Bonded El New Location ❑ Replacement ❑
Project Size: Express ❑ Standard V Lar>e ❑ Major ❑
Valuation:
2po , oB
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index.
Revised 6/16/08
•