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08100155 CITY OF CUPERTINO BUILDING DIVISION PERMIT ,CO1RAGTOR�IN'k`f.?-RNFATra,NN BUILDING ADDRESS: PE w NO. 21145 LAURETTA nR ATT,AS-TRTT,r,n OWNER'S NAME: PERMIT ISSUE DATE SA CONTROL NO. ARCHITEC(ENGINEER: BUILDING PERMIT INFO BLDG ELER PLUMB MECH R&R FURNACE & ADD A/C UNIT O O O O u a o LICENSED CONTRACTOR'S DECLARATION - to I bmcby affirm Nat 1 am limmadi muter prevision of Chapter 9(commerming Job Description U5 wiNSceram7000)oMmiine3ofthe Bush.and Professims, defmylicetseu j q<< in full force and If f/¢ ]J- Z Liccnan Chis _.d Da¢ Conuaau lz _—LAM"N W U 1 mrdersmnd my plans shut he used u Public records Da o � Licensed Profrstlonal 3 OWNER-BUILDER DECLARATION ii 1 hereby atTirm Nat 1 am exempt from the Contractor's Uccnw Law for the 00 following major.(Section 7031.5.Business and Pmfessiou Cade:Any city or county $ which requioes a permit to conswc,aper.improve,demolish.or nomir any strncaro zi prior to its scromee.alone mquims meapplicant furach permit to file sAtimedaacerml xx< that he is licensed pursuant In tM provisions of me Common's Uccmc law(Chaprm9 Sq.Ft.Floor Area Valuation F� (enmmcocing with Seem.7000)of Division3ofdsc Business and Profenal..Code)., — that he is exempt therefrom and the bias for the,alletrd!exemption My violation of Section 7031.5 by ary applicant fm a permit subjects Its applicant to a civil penalty of APN Number Occupancy Type not mart than ftw hundred dollars(55001 ❑1,u awmr of dk pmpmty,m my rmplaym wire wage u thew sok compeuadon, and de the wort and me smrmom s rot ssndedn Law de far oak(Sic.7014.owner os and cn, h bis Cade The Conwctor'm ndwho Law dm not apply lf an owner of Required Inspections oweem whores,proorimpeom thernteena who dmssucntened!imselfm0uaugs his thow..laym,providedmrsuch imPmwm within ice=Iintended!of moRermlfoe sale,If. however,the building mimPronmals meldwithin tete year of completion,the omer- builder will law me WAa of proving mat M did wt build or improve for purpoan of tile.). I.u owner of the property.aA exclusinly contracting with Demand antraerms to coutnmt the project(Sec.7016,Busirt and Professions Code:)The Contractor's Li- mean law dm not apply w an owner of property who builds or Wormers;Merton,and, who contracts fm such projects with a conuasem(s)licensed pursuant to the Contractor's Lken¢law. ❑lamesemp,tnder See ,BkPCforthisteamn Ower Date WORKERS COMPENSATION DECLARATION I hereby affirm under penalty of perjury enc of me fallowing declarations haw and will ro tiros n aCmtiGuteaf Conanntto seer-inure fm Workers Compete on.u provided for by Section 3700 of the Lsbm Code.for the performance of the w for which this permit is issued. I harm and will maintain Worker's Compensation Insurance,as minims!by Section of the Labor Code,for me performance:ofthe work for which this permits Issued. ' My War[k�ys Com creation Nsmanc nrtim and Polity nu-m�fberr sTer: Car! i Polity No.:j Z CEICTIFICATEO E?[EM rION FROM WORKERS COMPENSATION INSURANCE (ntis section road an,be completed ifdrs permit Is fee =hundred collect(SIM) m kis) 1 certify mat in the performance of to work for which this permit is leaned,1 shall oat employ any person in any manner an as m become mbject tome WoM1sn'Compensation taws of California Dae Applicant NOTICE TO APPLICANT:If,after resiling this Cenifinm of Exemption,you should become subject to the Wotimes Compensation provisions of the lairs Cade,you more 0 comply mply with such provss ms permit or permit shall be mooned rewkcd. .Zi M CONSTRUCTION LENDING AGENCY [-. I hereby affirm than Jerre is a couteuctinn lending agency for the performaoa of G' the waste for which ths Permit s issued(Sm.3097,Civ.C.) W� Lnder's Name , Z Landers Address V O 1 comfy that I have mad We application and sus that the shone information is It,^. arteck 1 agree to empty with all city and county ordinanm and ame laws relating to 01r.'J building construction,and heretoy aumorim mpmcnutiora of this city to enterupon hic W ahwe-mentioned property for inspection purposes gy (We)agree to save,indemnify and Incept hamlets the City of Cupertino against CA liabilities,juddmens.cow and experses which may in any way acme against said City L)z in c uegFree of dm dNAN of this permit. y /�Z ti Al UNDERSTANDS�SA'�WILL COMPLY WITH ALL NON-POINT Issued b Date SOU UL !� �0�2.�,�� Re-roofs Sr - ofAPPI' HAZARDOUS MATERIALS DISCLOSURE�- Type of Roof Will thc applicant or future Wilding P.M.aceuorhadk he ommus erasrial as dclInsd by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety cork.Section 25532(a)7 ❑Ye All roofs shall be inspected prior to any roofing material being installed. Will the applimrnl or future Wilding occupant use cyvipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove heradnu oI,commirmas as defirsd by the Bay Arm Air Quality Management all nK materials for inspection. ❑Yrs mNy I he.mai the hamadom Zterhil,rcquiremcnuunJcr CluPmr6.95 ofdm call[.- .25 alif.- -` yx ns Hnith rycodc.Say.25505.75533 tad 255M.IvodvvanC thnifthc ddlNng JU12210 � (� Jm not c Nor a snare,ma it s my reapomibility to notify me occupant of the / mquimm wh muthc otoissuascofaCcniOcesoffkcuparry. fj Signaureof Applicant Date °/ All roof coverings to be Class'W or better Owne amcd agate Community Development 10300 Torre Avenue r E� Cupertino CA 95014 ~ Telephone(408)777-3228 CITY OF Fax(408)777-3333 *UPEI,TINO Building Department JOB ADDRESS: PERMIT # - gR001SJ O R'S NAME:gfk1g, ( PHONE # p GENERAL CONTRACTOR: a' j FAX # I am not using any subcontractors: C� Signature Date Please check applicable subcontractors and complete the following information: 66 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 on actor Signature Date CITY OF CUPERTINO • 6 ITEMS OF 12 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32655015 . 00 DATE ISSUED. . . . . . . : 10/23/2008 RECEIPT #. . . . . . . . . : BS000006450 REFERENCE ID # . . . : 08100155 SITE ADDRESS . . . . . : 21145 LAURETTA DR ' SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : RAHARDJA IMMANUEL ADDRESS . . . . . . . . . . : 21145 LAURETTA DR CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1662 RECEIVED FROM . . . . : ATLAS-TRILLO CONTRACTOR . . . . . . . : TRILLO, STEVE LIC # 4269 COMPANY . . . . . . . . . . : ATLAS-TRILLO HVAC ADDRESS . . . . . . . . . . : 1965 KYLE PARK CT CITY/STATE/ZIP . . . : SAN JOSE, CA 95125 - TELEPHONE . . . . . . . . : (408) 286-8931 • FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL - ---------- ---------- --- ---- --------- --- 1BSEISMICR VALUATION 9, 700 . 00 1 . 00 0 . 00 1 . 00 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 1MRRAA UNITS 2 . 00 122 . 38 0 . 00 122 . 38 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 286 . 54 0 . 00 286 . 54 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 511. 39 #9780 --------------- TOTAL RECEIPT 511.39 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- - ------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL • d� o015,_3 CITY OF CUPERTINO Sam FURNACE/AC riffy OF 0CUPEkTINO PERMIT APPLICATION FORM APN# / Date: - 3A CO_S -- Building Address' 1 ( , `s Owner's ame: 1 Phone #: Contractor: Phone #: �3 O� L C,9 Fax #: Contractor License#: Cupertino Business License#: X137 Contact: ,n Phone#: p 5( ✓ , l Fax #: Building Permit Info: Elect [�' Plumb [-- Mech Residential F1 Commercial ❑ Job Description: For Residential Installations: Attic ❑ I" floor ❑ 2nd floor ❑ Adhere to minimum setback 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 (Usage Class): A � a V0 Strapped F1 On Platform El Bonded EJ New LocationV I Replacement Project Size: Ex ressE�--Standard ❑ Large ❑ Major ❑ Valuation: 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. C- Revised 6/16/08 s CITY OF CUPERTINO �Q FURNACE/AC or > CUPEkTINO FEE SCHEDULE • Quantity Fee ID fee Description Fee Permit Type Group FURNACE FURN/AC 1MCRAA Commercial-Repair/Alteration/Add to M ea heating appliance,refrigeration unit, cooling unit,absorption unit,or ea heating,cooling,absorption or evaporative cooling system incl installation of controls regulated by this code. 1MCREPALT Commercial for the repair of alt/add to M ea heating appliance,refrigeration unit,cooling unit,VAV boxes, absorption unit or ea heathing, cooling absorption,or evaporative cooling sys, incl install of controls regulated by this code. 1MCSUSHTR Commercial Install/Relocate ea M suspended heater,recessed wall htr, or • floor mounted unit heater. 1PGASCOM Commerical for ea gas piping System P 1-4 outlets 1BPGAS For each gas piping system of 5 or P more per outlet. 1MCAPPVNT Commercial for the install/relocate/ or M replacement of ea appliance vent installed & not incl in an appliance permit. 1BSEISMICO Commercial Seismic B 1MRRAA Residential Repair/Alteration/Add to M ea heating appliance,refrigeration unit, cooling unit,absorption unit,or ea heating,cooling,absorption or 1/ evaporative cooling system,incl installation of controls regulated by this code. 1MRSUSHTR Residential Install/Relocate ea M suspended heater,recessed wall htr, or floor mounted unit heater. 1MRAPPVNT Residential for the install/relocate/ or M • replacement of ea appliance vent install &not incl in an appl permit. Quantity Fee ID Fee Description Fee Permit Type