08110092 CITY OF CUPERTINO �
BUILDING DIVISION PEig 'j' W.
.. ONTR.AiC�TO,R1�,O,aRM41�C,IEN,
BUILDINGADDRESS: PERMIT NO.
1'0198 N PORTAL AVE CONDITIONED AIR opti 1 nog?
OWNER'S NAME: PERMIT ISSUE DATE
A CONTROL NO.
NE:
(408) 291-2220
ARCHIEC/ENGINBER: BUILDING PERMIT INFO
BLDG EfECi PLUMB MECH
�o Z' LICENSED CONTRACTOR'S DECLARATION _ Job Description
U 1 hereby&frim this 1 an li¢lucd under provisions of Chapter 9(esene
mming
wide Satlon] of Division Sof dens Bud Prof mad myliccnau
�N insert a (� RMV & REPLC FURNACE & DUCT WORK
z u« J ts.a
=Fp Dale Co..,
swwyv ARCHITECTS DECLARATION
< 1 uMcrsuml my plans shall he used as public recoils
ME.)
y o
� ense
Licensed Pmfcssional
5 OWNER-BUILDER DECLARATION
f 1 hereby affirm that I am exempt(rum the Canl Ors Licente Law for the ,
p O following m,."n.(Section]031.5.Business and Professions Cade:Any city us..my
la ff which rcgrhea a permit m consomel,alter,implet ducedish,or repair any suucome
_I< prior b W jummee.also lCyalmS the applicant for such Pemlll ut rile a signed susumunl
E thuheulicensedputmaltroNcprovisbnaf&ContrectorslxerueLsw(Chapter9 Sq.Ft.Floor Area Valuation
t� (commencing wide Section 70010)of Division 3 of the Business and Pmfeaions Codc)to
y 3 that he is comp,therefrom and the basis for the alleged eaanptim My vitiation of $7760
Sation 7031.5 by any eppOanL for a Permit mhiau the appliunt to a doll Penalty of APN Number Occupancy Type
nal mare there(Irc hundred dollar,ISM 31628055 . 00
❑I.uawnerofthepnpmty,mmywpioymwiNwagnude4mlccompewdm,
will do the wcck and Neswcture boost mundedaraffered lcrsele(Soc.8114.Business Required Inspections
and Pm(etaions Cede:The Consensuses License Law dm rot apply m an owner of q p
propeny who builds or impmwsIA mens.and whodoessuch werkhimalfvdhough his
own employceat provided that such improwmenla are not intended oroRrrd for We.If.
however,the building or improvement is sold within one year of completion,the owner, -
builder will have use,brides of proving that he did rot bund or improv for purpose of
ale.).
❑1.as awns of the property,w esela daely cons emg with licensed mnuactaa to
mvsun the prEj=(Sec.]044,Business and Pmfesnom Coda)The Consumes U.
cave Law dm not apply m an amu of property who builds or improves thereon.ad.
who comaracm for sled pmjcas with a conalLtor(s)licensed pursuant m the Cesmclars
Liana Law.
❑lamaemplmder See .BhPcfvdeureason
Owner Data
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following decimations:
1 ham and will maintain a Canifnate of Covent to self-ivu c for WO,kerlCOrePCn-
tion,as Provided for by Section 3700 of the labor Cade,for the pmfomana of the
wart for which this pared,is issued.
0 I have send will maintain Workc r Compensation Ilsaana,u noquired by Section .
3M of the labor .for rvedo ase of the wvkfm which lbs pemuuissued.
My Workefs y u a 'u and Pao nit�nb .
Gorier. Policy No L`�_
CERTIFICATECOMPENSATION
EXEMPTION ON FRAM ORKERS'
COMPENSATION INSURANCE .
(This mcdon reed net W completed If lie pemit Is forane hundred dollar(SI W)
M Ica)
1 an ify Nat In the perfomaaa of on,work for which this permit is Wood.I shall not
employ any person in my mannerm as Or became subject w lad Worker'Compensmon
LJws of California.Date
Applicant
NOTICE TO APPLICANT:If.slur making this Certificate of Exemption,you should
become subject to the Wok s Compcvatim provisions of the Mbar Cade,you most
.,O forthwith comply with such provisions or this permit shall W dared rewked.
z CONSTRUCTION LENDING AGENCY
1 hereby affirm that,there Is.co.tm leading agency for depMomaoox of
0:> the work far which this pemu is issued(Sec.3097.Civ.C.)
AL<ndces Name
z Lenders Address
V 0 I anify deer I haw read this application and solo the the above informed.b
V.!' correct.I ague m comply with all city and county on inanees and aisle law slating m
.O building conswc,iun.and hereby authorize reptemnolivu of this city in envy upon the
r 4 oho d property fm inspe n pogroms
(Wq a arc.iadcmniry hamka le UCity of Cupertino against
if'i h Ilabilitin,)ndgmcn mad expessea hich in any wy acerae ag Iseid City
fJ Z in cansequena of the of this peer
�-' APPLIC NT UNDERSTA ND WI COMPL ITH All.N N. Issued by: Date
SOURCE FAULATTONS. - ��
S Re-roofs
signora of AppliaHAZAR O are
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
WlllladeCupentor future Wildingacupantsmzem Inosite Health anmaterial
u de0ned io the Cupenim Mu ipal Calc.Chapter 9.1).mad rile Health old Safety -
cadc.Secure zss3z(a1] //ny}cc All roofs shall be inspected prior to any roofing material being installed.
❑Yea PNa
Will the applicant or fmyyyccc building acupant um equipment m dcvim which If a roof is installed without firs[obtaining an inspection,I agree to remove
h 1uE,mJnv ai,cmmmivnyar dc0md by the Bay Arta Air Qualify Management all new materials for inspection.
vim?
No
I have read materiass requimneno under CTaper6.95oftheCalifm-
Healde& afct Soaiw]5505,25533a M34.iundcmandthuifthe Wilding .
rot n tenth 't u my 'Idltly m mtiry the aeclpNI or the
ME,,, meow her= I taneeo eateafO pvey. Signature of Applicant Date
Owner orauthori edagcnl Dam All roof coverings to be Class'W or better
CITY OF CUPERTINO
O 7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 31628055 . 00
DATE ISSUED. . . . . . . : 11/25/2008
RECEIPT # . . . . . . . . . : BS000006690
REFERENCE ID # . . . : 08110092
SITE ADDRESS . . . . . : 10198 N PORTAL AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : LEE KENNETH N AND JEAN G
ADDRESS . . . . . . . . . . : 10198 N PORTAL AVE
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2323
RECEIVED FROM . . . . : CONDITIONED AIR ASC
CONTRACTOR . . . . . . . : RICHARD READ LIC # 22334
COMPANY . . . . . . . . . . : CONDITIONED AIR .
ADDRESS. . . . . . . . . . . : 1701 LITTLE ORCHARD ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408) 291-2220
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ----- ------- ---- ----------
1BREMVENSY NO UNITS 1 . 00 91 . 79 0 . 00 91 . 79 0 . 00
1BSEISMICR VALUATION 7 , 760 . 00 0 . 80 0 . 00 0 . 80 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 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 378 . 13 0 . 00 378 . 13 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 378 . 13 #6703
---------------
TOTAL RECEIPT 378 . 13
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ------ ---------- -------- -- ------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
Ohl 00
CITY OF CUPERTINO
It
,1 512- FURNACE/AC
CUPEkTINO . PERMIT APPLICATION FORM
APN # *516 • Z ' O o Date:
Building Address: 1 I ZS
10198 N . m3y2k 00;)e(vy%v10 CA q$01c(
Owner's Name: Phone#:
lame" c as 7-45,5 . 1599
Contractor:
Phone#:
C Oro:%ili,o�1L d �1�` `�r�SS O C. Fax #:
Contractor License#: Cupertino Business License#:
'A4 516 7Z-
Contact:
Contact:
Phone
x # #: �1AemE
�jErv --�V2d`Oi1
Building Permit Info: Fa :
Elect [o]t� Plumb ElMech
Job Description:
(2+e!'rYiO(R 1 .�te,(�l'� `rrve+•t12CP j �Gk Ca)0•f'�G
Residential Commercial
For Residential Installations:
Attic ❑ I" floor 2nd looI ❑
Adhere to minimum setback requirement ❑
For Commercial Installations:
Replacement same weight N- Additional weight (structural talcs) ❑
Structural Calculations required for new installation ❑
New installation PlanningApproval Required ❑
Cost of Project: Type of IConstruction (Usage Class):
Strapped On Platform LJ Bonded New LocationReplacement
Valuation:
• �6 0 . 00
Green Building: Must attach Green Building Check list to this application