08100188 CITY OF CUPERTINOf*:sx-«. +�a�rS urt y'd' '�> ' 7M
BUILDING DIVISION PERAUT CO R T1 I+'OItMA.TI�N ..
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: PERMIT ISSUE DATE
SA CONTROL NO.
ARCHI'IECI7ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
REMOVE & REPLACE FURNACE
c O o LICENSED CON It ACIDWS DECLARATION
u F 1 thereby affirm Net 1 am luxaed under pmvisimu of Chapter 9(Wermcociot Job Description
U`uf with Section 7000)o(Division 3 of Ne Business send Profeuimu Code.,cal my It.,.I.
ufuieltl�forte aMe a Lk.• �GV Y1 ` _ .
k- pate O— Conlnctm
e'e < ARCHIIE(.TS pECLARATION
t U I underwnd my plans
Mall be used as public rtcmd;
Su.O t^ Idccnad Profcnaimtsl -
7N� OWNER-BUILDER DECLARATION
4 E I hereby affirm that I am exempt from the Contractor's License Law for tis
too fallowing„•,.^o(Scetioo 70315,Business and Professions Cade:My city or county
which os utra a permit m eonarsmet,¢ler.imprse,demolish,Or repair any structure
xi Pnofto its iuuancse.alsurequima ds applicant forsueh permit refile asignedststemcm
C
that hculicensed pursuant totopmvislmuofthe Contractors Liceme,Law(Chapter 9 Sq.Ft. Floor Area Valuation
�3 (commencing with Section 7000)of Divisions of the Business and Professions Code)or
Q dist he Is emesis thunffmn and t s basis for the,singed eaernptims My violation of
Section 70315 by any applicam fm a permit subjects On APpinut to a civil P.ILY of APN Number Occupancy e
am,come Nan ftw hundred dollars(5300). P y •T]ye P
❑I.uawar of Ne pmapaty,mmy wplaytts with xguu Nen sok emnpemation,
wiRdothework.mdthew mi3mikmM waReredfmaale(Sm.7044,Busineu
and Prof..if.Code:The Contractors Liana law dale cot apply to an owner of Required Inspections
property who buildamimpmwa rhareon,and whodaes mchwmk himself.through his
owncmploy ns,proNded that such imp owneenu art not intended oro@ned ferule If.
however.the building Or impnaswent is sold widen one year otcompkdon.the Owner.
hailda will haw the bmdrn of proving that he did not build or impose for purpose of
sale.).
1.as owner of the popery.am eelusiwly contracting with licensed cembferra to
emltroet the project(Sec.7Wa.Excrete and Pmfessiom Code:)T1s Cmuec7ors V-
ceme Law dote not apply to an owner of property who builds of impress IhLecon.and
who concocts for such projects with a conuaetor(s)licensed pursuant to time Contractors
License Gw.
I ore..in undo Bee ,B&P C Ire this rests.
Owner Date
WORKER'S COMPENSATION DECLARATION
IntoI hereby Alm under puWty,of perjury arc of Ne following decluauormc
,haw xM will mximain a CudOmu of Consent tostlf-imurt fm WaMYCompen-
rion,u provided fm by Section 37(10 of the Labor Code.for Ne perfomsemc of thc
work for which this permit is issued
❑I haw and will maintain Woftes Cooperation Insurers,as required by Session
3IIM)of Ne labor Code.for the Performs of the wort for which this permit is lured. '
My Workers Cnmpewtim Insurance carder and Policy number art:
Came, n.;sv4 va-L S. Pofsy No.:1 C I O Zl;7
CERTIFlCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Tndssectine rcN rotbeconpleted Lime permit is fmooe hundreddoBan($100)
or lose.)
1 certifv Not in d e performance of that,work for which this Permit is Lssucd,I shall not
employ any person in any manocran u to become subject to the Work=%`Compensation
Laws of California.Dam
Applicant
NOTICE 7D APPLICANT:If.after making this Certificate of Exemption,you should -
become subject to the Worker's Compeaktion previsions of the labor Code,you most
O forthwith comply with such pmviskom m mu permit shall W domro
ed oked.
Z " CONymucnON LENDING AGENCY
1-n 4 1 hereby M.door Ncre is.convection lending agency for the perfomane..I
Di 7 the work for which this permit It issued(Sec.3097,Civ,C.)
QUndoes Name .
z Lenders Address
U Q 1 certify that I haw red We application and esu Nat Ne above information Is
lS. comem I agree to comply with all city and county Ordinances and sate laws reeding N
_O Wilding construction,aM hereby aurhddm mepmsenutives of this city m eater upon me
above-mentioned property for inspection purposes
py (We)agree to sew,indemnify and keep hasmleu the,City of Cupertino.gaimt
ti liabilities.judgments,cow ted expenses which may in any way accrue agaims said City
U z in
^ cameqae gang of Nu permit.
APLICAANDS
AND
WILL COMPLY WITH ALL NON-POINT Issued by: Date p2,�iGC�
SOURCE ONS ��a.�q
Sigryl o ppfinnUCanuacm Date
Re-roofs C:;2
HAZARDOUS MATERIALS DISCLOSURE Type of Roof .
Will Use applieut or future Wilding occuprtsme or handle ha udous material .
of deRxd by the Cupenim Municipal Code.Chapter 9.13,and the Heath and Safety
Cade,radon 35533(.)± All roofs shall be inspected prior to any roofing material being installed.
❑Ya 1211.
WitWill the aPPIWME or future building occoprot use equipment or devioes which If a roof is installed without first obtaining an inspection,I agree to remove
hauNou air cmummums u defood!by the Bay Arta Air Quality Management all new materials for inspection.
n7 V
Ya
I have read the hmar0ow mseerlals requiremcnu umlefchapter6.95of0s Califon-
nuHealth&SafetyCode.Savms25505,35533 and 35534.1 unknownW thseiftime buikkj
Af
t ofmkSignature of Applicant Date
All roof coverings to be Class'W'or better
Dau'
CITY OF CUPERTINO
• 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . -. . . . . 36654012 . 01
DATE ISSUED. . . . . . . : 10/29/2008
RECEIPT # . . . . . . . . . : BS000006491
REFERENCE ID # . . . : 08100188
SITE ADDRESS . . . . . : 11652 VINEYARD SPRING CT
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : WOLFGANG ADERXOLD
ADDRESS . . . . . . . . . . : 11652 VINEYARD SPRING CT
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5135
RECEIVED FROM . . . . : A & H HEATING
CONTRACTOR . . . . . . . : PHELPS, DALE LIC # 12079
COMPANY . . . . . . . . . . : A & H HEATING
ADDRESS . . . . . . . . . . : 770 CHESTNUT ST
CITY/STATE/ZIP SAN JOSE, CA 95110
TELEPHONE . . . . . . . . : (408) 279-0722
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 4, 450 . 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
1MRRAA 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
----------------- --------------- --------------------
CREDIT CARD 224. 85 MASTE CARD
---------------
TOTAL RECEIPT 224 . 85
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---- -------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
•
CITY OF CUPERTINO
FURNACE/AC
aC10F
• CUPERTINO PERMIT APPLICATION FORM
APN# Date:
2 .0 I
Build n Address:
Owner's Name: Phone#:
(-- Oe .,D 10IS111 �y4
Contractor: Phone #:
I�] 2�� x712
l/ 14T-6-- _ Fax#: 27C' /on
Contractor License#: Cupertino Business License#:
Contact: ••(n� Q p Phone#:
04 — � f S Fax #:
Building Permit Info:
Elect � Plumb ffr Mech
Residential Commercial
AML
ob Description:
12cYn-w(/e d (�ePl � �r� ►vc�
For Residential Installations:
Attic ❑ I" floor 0— 2nd 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 of Project: Type of Construction (Usage Class):Strapped On Platform Li BondedNew Location ❑ Replacement
Project Size: Express ZK Standard ❑ Laz e ❑ 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 81 the sheet index.
Revised 6/16/08
411
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w.. Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
WUPERTINO
Building Department
JOB ADDRESS: PERMIT #
SSL F/wt _ 2w>ic, CT— op?"W/cff
OWNER'S NAME: Gia/fGjVegj,ecA9. PHONE # v�
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
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
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date