08120038 BUILDING DIVISION PERAUT y��r01v 4 ""GTOR NKQRMATICI V
BUILDING ADDRESS: PERMIT NU.
21791 OLIVE AVE PERFORMANCE A
OWNER'S NAME: PERMIT ISSUE DATE
–1 TN Sli
NE: SA CONTROLNO.
ARCH=1ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
INSTL CENTRAL HEATER & A/C
20a LICENSED CONTRACIGR'3 DECLARATION
1 hereby affirm Nat 1 Am licensed under provisions of Chapter 9(commencing Job Description
with section Taro)ofDivlalon 3 ofth.Business and Professions code.am my license I,
in full to=And cfran. 6 1
j license Class Lk.N ,
aFp Dom Contractor.
eqq 7W ARCHITECTS DECLARATON
y 2 U I understand my plans shall W used As public record,
N G� Licensed Prefe sional
cy3 OWNER-BUILDER DECLARATION
f 1 hereby Affirm that I am exempt from the Cenatndes License Law for the
p 0 following reason.(Section 7031.5,Business And Profusions Calc:My city or county
e;9 which requires A permit m construct alar.Mprow.dcmnlah,or repair any.=to.
–Zi prior to its issuance,Alan rtquims the applicant far such permit m file A signed sWcmen,
< thatheislicensedpmso.coatncpm.islonsartheChambersLiceneLaw(chapter9 Sq.Ft.Floor Area Valuation
YFC (commencing with Section 7")9Division 3 at the Business and Professions Code)Or
15 9 that he u exemptm,hem(roand the basis for the alleged exemption Any Holatlo)a(
Sued.7031.5 by say Applicant fm A permit subject,(.Applicant W a-Ml penalty or APN Number Occupancy Type
oar mom man BK hundred dallac,(s5=
❑I.u cans of the propvty.m my wployeca Wim cages u de'vselecmnpcwtion,
wine.(.wort roe(.he C.m amtinLMederaw dialect
AD
Badness
aced property wh oro Cao:Tat.canuecmrs License Law Gees oat Apply W m wtter ter Required Inspections
propertywho Wilda of imprasesch imrandwho deoetchweakhimselfer(mage his
Own employees,proHded that such improvedw it Are ata iear,of
Or mpluued for,sale If,
Wilder me Wilding orimprowmmtg sold withinone year of mmplmifor theose of
sale.). will Nva Use burden of proving Nat he did m,Mild or improve(a purpose a(
nleJ.
jZr[,As owmr of the propert,am vcl"wiy contacting will,licensed mntcmrs W
mtc sect th.pm)en(Sec.7014.Business and Rafetians Coon)Th.Gaaeaewel{-
cove Law dens not apply As an caner of property who builds or inn rows(aeon,And.
who contracts for such projects wit a comncmn(s)licensed pursuant W the Convaetoh
License Law.
E]I ren exempt undo S/5g' / /s—,/ -- B&P C far this mss_aA
owner �&- L=— d'✓ Data 1 S/46pt0
WORKER'S COMPENSATION DECLARATION
I hereby Amro under penalty of perjury,am at the following declarations:
I h,As atW will for
b in a tmn 3700 o(Covem W Code.fure(tar performance
a cempen
tan,r hick this
rpe mi sectiar d. or the Labor case.for(.pedamtma or(.
won for cameo this permit a i,smtl.
❑1 hale and will maintain Worker's Compensation Insurance,As required by Section
37W of the Labor Code.for the performance of the,wort fwwhich this Permit Is issued.
My Worker.Compendium.Warmness artier aM Policy number are:
Cartier. Policy NO.: -
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
Rha saedm head rot he completed Bene Permit is f«am nWtmedaollars(elm)
ar less)
1 cenuC,v that In the performance
rroff�ine Wwod far which this Permit a aced.I shall no,
employ any person in any moll
/6/9+mmpbj..t ro the WOrlmx,'Compensation -
Iaw,ofCAIfl5 ice.DUF P
Applicant rl Qat�I
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,yam should
become subject W the Wooers Compensation provision of the Ialwr Cod,you most
.7 z forthwith comply with such p...We.Or(is permft shall w decmed rawted.
z "' CONSTRUCTION LENDING AGENCY
[–m 4 1 hereby afrrm tha,,hem is a construction lending agency for the Performance of
D:mom„ the won for which this permit Is issued(Sec.3097,Civ.C.)
Landers Nun. ,
D z Larsen,Md....
C)Q I certify that I haw read this application And,ISW that the Above information is
0.F cormct 1 agree W comply with all city and county andinuees And sued laws relating W
.Q building construction,and hereby amhotim represmtairm of this city to ever upon the
Wahow-Wombeed property fm inspersion pugwsen
(We)Agra to eve,indemnify and keep barmy the City of COPChine against
r h liabilities.Judgments.cru and expenses which may in any way amueAgainst said City �7
V z of the madng of this permit,
APPLICANT UNDERTTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
soyy REc}lun7 � p 0-/4/�-J` Re-roofs
Signature of AppH.VC.. .r Dae
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Wit the wpit.,or future wilding occupants om or handle haardoes maWrw
an defined by the Cuputim Municipal Code.Chapter 9.IL and the Health and Safety
Code.Section 25533(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yrs INA
Will the applicant or future wilding Occupant use egaipmm,ar dCw Cas which If a roof is installed without first obtaining an inspection,I agree to remove
t haesm..air contaminants As dcftned by(e Bay A.Air Quality M...gcmcnt all new materials for inspection.
Neale'?
❑Yes EINo
Ihaw Wad(ehvxlLUs mawdalsmquimmenuundarChapmr6.950ftheCalifor-
niaHalm&SofctyCodc.Sca=25505.25533am125534.1 WWm=d(eif(c wilding
dace rot cunenly Mw a enanl that II i,my map.nsiMlitY W notify tie mmpmt of lone
ramre ntsyn ust,lx _arWisstc.c.facerifi.aeafcccapen.y. Signature of Applicant Date .
J 1�4� All roof coverings to be Class'%}"or better
Owner Or authori=d agcni Dae
CITY OF CUPERTINO
• 6 ITEMS OF 12 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35718029 . 00
DATE ISSUED. . . . . . . : 12/04/2008
RECEIPT # . . . . . . . . . : BS000006747
REFERENCE ID # . . . : 08120038
SITE ADDRESS . . . . . : 21791 OLIVE AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CHIA-LIN SHIH
ADDRESS . . . . . . . . . . : 21793 OLIVE AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : CHIA-LIN L SHIH
CONTRACTOR . . . . . . . : TIM STANFORD LIC # 27768
COMPANY . . . . . . . . . . : PERFORMANCE AIR SERVICE
ADDRESS . . . . . . . . . . : 1805 LITTLE ORCHARD ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408) 920-6170
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 10, 493 . 00 1. 10 0 . 00 1 . 10 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 . 64 0 . 00 286 . 64 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
--------------- --------------
CREDIT CARD 573 . 18 MC
---------------
TOTAL RECEIPT 573 . 18
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- -- ------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
•
Community Development
10300 Torre Avenue
iiy4I Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
OUPEkTINO
Building De artment
JOB ADDRESS: PERMIT
X 1'14 ( Ave -,a �1� / 2 as�1
OWNER'S NAME: C a-6 :1^ PHONE # 40E- '70
GENERAL CONTRACTOR: Q ance FAX # 40R— >-D - 111
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
CITY OF CUPERTINO
FURNACE/AC
O
:CUPERT`INO PERMIT APPLICATION FORM
APN # 357/6 0Jq . Date: I Z A
Bui di Address:
zl � c� �i ;r
u2 4 . G o
Owner'�-,h Name: Phone #: 65-D-914-
A—
Contractor: Phone #: C qg')1>�O 617 o
Fax #: 408 — ctx'— 6 f 7
Contractor License#: Cupertino Business License#:
56133
Contact:
,r II Phone #: (��— �1 —48,7,2
Fax #:
Building Permit Info:
Elect D---' Plumb Mech �—
Residential 21 Commercial LJ
ob Description:
A c
For Residential Installations:
Attic ❑ 1" floor ❑ 2"d 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):
Strapped On Platform ❑ Bonded 0 New Location Replacement
Project Size: Express tandard ❑ 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.
Revised 6/16/08
d� CITY OF CUPERTINO
FURNACE/AC
CITYCUPEI�TINO 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
113PGAS 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 ¬ 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
Ievaporative 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