08120021 CITY OF CUPERTINO
BUILDING DIVISION PERMIT RCeO Rr1C"'TURNFO aRM TION
BUILDING ADDRESS: PERMIT NO.
10769 W ESTATES DR TBD — TO BE—PETEEMINED— 08120021
OWNER'S NAME: PERMIT ISSUE DATE
ManczWNT Tf
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A 0. CONTROL NO.
LONE:
ARCHI EC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
woo LICENSED CONTRACTOR'S DECLARATION Job Description
V 1 bemby aRrm IMI I am li¢vrd under pmviJons of Chapter 9(Commencing
with Sccamn 7010)of DiHJon Sof the Buunewand Pmfession+Cede.and ney liecve is
'o imm"fweeaCid 'fl '1 �-� ZQ-S FURNACE CHANGE OUT— GARY' S FURNACE SERV- PD FOR
Z License ssa L/%N Lk.N
Dam ll-7 —/1F CO.. BUS
ARCHIECTSDEC TION
` IumicommdmyplauahJlbeumdupu records LIC 12/02/08
;6
g G C', Licensed Pmfcstiourl
OWNER-BUILDER DECLARATION
E I hereby affirm That 1 am eacmP,from dee COnuacto's Licrnm Law for the
OO following ma mn.(Section 7031.5.Buureas haul Pmfesdoa Code:My city or County
C
3 ff which mquima a Perron,to conawca alcor.Winnow.demmlash.Or repair my s0ucture
poor 0 its issuance.•lto requires the appikket for such permit to rile a sigsmd aammenl
< that W is licensed pmmsnt w the provistoa of tie ConOacwr's Lmoom Law(Chapter 9 Sq.FC.Floor Area Valuation
e€O (commencing with Section 7000)of Division 3 or dee Business and Prefesooln Code)or
y that W is exempt themfmm and the buss for the Mcged exemption.Any Holatimn of $1850
Section 7031.5 by airy applicant for•permit mbjma the applicant w•Civil penalty of APN Number Occupancy Type
not mom dean fixe hundred dollars(SM. 36923029 . 00
I,uawrmj of the ptvprty.mmy wployms with wagn uthe'v mkcamprnutioe
will W Ihewares and tie he Com awt s LicenE or row du fmhak(Sec.70th.BLLJneha
and mywhma Code:The conmmmrs ndwhe Lew area ret appy f art mwma or Required Inspections
is
awo enrwW WiMamimprowsat ch improvements
mpr ve who am not mworkhi Offredmmugth It
mwnemp.the Wilding
or improvement impmwm wain COO ourofCmoOertdfmoea-
hmweor Nebuildingm knoissetawidest et Sear or Compktim,the ordof
Wilder will Nw the burden of poling Nat W did ret build or impaw Ler puryom m(
❑h u owner of the property,am emlutivdy contamting with licensed conuamors to
construct the project(Sec.70aa,Buineas and Proksdons Code)The Contractor's U.
come Law doss not apply m an owner of property who builds or improves aemon,and.
who Contracts for such pojetts with a eonmactor(s)ticoued punt to dee Conumtoes
I I—law.
Iamammpunde See .BkPCf.ttd—ren
owner Dam -
WORKERS COMPENSATION DECLARATION
1 thereby abuse under potty of perjury mm of Ute folbwing declaroa nke
him and will maintain a Cudficam of Coaem anaelf-insure fmwavemexcompen-
Ion,u Provided for by Section 37M of the Labor Code.for the performance of the
work for which this permit is issued.
0 1 have and will maintain Workers Compcaation Insurace,as mquimd by Section
37Wof dee(Aber Code.for the performance of the wort for which this permit is Issued.
My Wmrkota Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
mbetaeca m coed ml W complemd if the prom is(moot hundred!dollars($100)
or ksa)
1 Certify Not in the,performance of Ue work for which this Permit is wood.1 shJl not
employ any person in anynonnermumbecomcmclmO Wo brwCompensation
-
Laws of DN umt m n - 1r 0
Applicant � A
NOTICE To APP CAM:IL and i Nis Cenifmam of Exemption,you Amid
becidne tubjm, the wohrh Compeaadon proHJoa of t e Labm Code-you main
.,O forthwith comply with such provisions m Nis Permit shall be dmmeaw
mkcd.
Z CONSTRUCTION LENDING AGENCY
I hereby aRren dead them ilacma Am lendingapacy,for the forferm.of
C r7 Ac wake for which this permit is issued(Sec.3097,Civ.C.)
W0.25 LendeYs Name
z fender's Address
U O 1¢nifY that I haw read this application and stare this the above information is
1, P camel I agree to comply with all city and county Ordinances and sum laws relating w
.0building construction,and hereby authmrim reprommatiws of this city menmr upon Ne
W +hove-menta
iod property for impccamn purpaes
pry (We)agree to have,indemnify and Iump harmless the City of Cupertino against
N liabilities,jndgmcnu.costa and expmua which may in my way ac kinat said City
U z in comeet.of the granting of this prmil.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R ULA ONS. .
Re-roofs V�
Salina f pplican✓COn r Dam
HAZARDOUS 14 ALS DISCLOSURE Type of Roof
Ill ate applicaut or future Wilding mcapantaom or Aandlo havldoa mamriat
ka de d by Ue Cuperam Municipal Code.Chapter 9.12.and dee Health and Safety
Code.section M532(a)7 _/ All roofs shall be inspected prior to any roofing material being installed.
Yu o
Will dee applinsnl or future Wilding Ormpmt um equipment or devise which If a roof is installed without first obtaining an inspection,I agree to remove
h harndoa ur commonana as defined by dm Bay Amt,Air Q Any Managemcm all new materials for inspection.
ct7
❑Ya p 9u
I have mal the havrdo gromuiah mquimmemaunderchapmr6.95oftheCalifor-
nisHcalN&SJctyCode,Sued.25303.25533 a0125534.I undersand lhadifac building
doss not turn haw+=Wan thatitbmymspeaibilitywnoufytWoceupmtofthe
mquiremcn her be mrwisseanComfaccnifecmor0ecupuey. Signatu
3re of Applicant Date
72Z �
Ow=m mimdagent Dam All roof coverings to be Class'A:"or better
' CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36923029 . 00
DATE ISSUED. . . . . . . : 12/02/2008
RECEIPT # . . . . . . . . . : BS000006729
REFERENCE ID # . . . : 08120021
• SITE ADDRESS . . . . . : 10769 W ESTATES DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : MADSEN, K
ADDRESS . . . . . . . . . . : 10769 W ESTATES DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4535
RECEIVED FROM . . . . : GARY' S FURNACE SVC
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . .
TELEPHONE . . . . . . . . :
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- --- -
1BSEISMICR VALUATION 1, 850 . 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
----------------- --------------- --------------
CHECK 224. 85 #6501
---------------
TOTAL RECEIPT 224. 85
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- ------ -------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
•
Community Development
1 . 10300 Torre Avenue
J' Cupertino CA 95014
" Telephone(408) 777-3228
CITY OF Fax(408)777-3333
*UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
10 6,5 Uja fe�- /Z
OWNER'S NAME: ry�aols*M PHONE # 6 7- P/
GENERAL CONTRACTOR: Y, ( Ajn (( r-��t FAX #
I am not using any subcontractors: ( 2,
Signature Date
Please check applicable subcontractors and complete the followin 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
/ Z 2 ' dd
Owner/Contractor Signature Date
' o� iaooal
CITY OF CUPERTINO
FURNACE/AC
C1 OF
•CUPERTINO PERMIT APPLICATION FORM
APN # ( 0 a q , 0 Date: — --Z—r
Building Address:
6- �S
Owner's Name: Ph ne#:
(n fA s--e-n o�-
Contractor: Phone#: Wo , 9(.1 _ 1
Y Fax #:
Contractor License#: Cupertino Business License#:
Contact: Phone #: U_Q 6 - d,1 -7 1
�C7 M l
Fax #:
Building Permit Info:
Elect ®� Plumb Mech
Residential Commercial
Job Description:
�GLV`VUVc-u GG-r��
For Residential Installations:
Attic ❑ V, floor I . 2"d floor ❑
Adhere to minimum setback requirement ❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural c_alcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of ction (Usage Class):
Strapped On Platform ❑ Bonded ❑ New Location ❑ Replacement
Project Size: Express ❑ Standard ❑ Large ❑ Major ❑
Valuation: /� w
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. 15--
Revised
5_Revised 6/16/08
CITY OF CUPERTINO
a FURNACE/AC '
CUPERTINO FEE SCHEDULE S
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.
IPGASCOM Commerical for ea gas piping System P
1-4 outlets
IBPGAS 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,
rcooling unit,absorption unit,or ea
I heating,cooling,absorption or
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.
1 MRAPPVNT 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
Grojun