08120039 CITY OF CUPERTINO i.� sl�a>a ax., gsy*�€r "�D� "���"y'��'�'�' �'`•�"f�1`�'�w1 �'
BUILDING DIVISION .PERMIT 104T!i�V�J4 QA4 Zs�•�� �IvLF r
BUILDING ADDRESS: - PERMIT NO.
21793 OLIVE AVEPERFO
OWNER'S NAME: PER'WT ISSUE DATE
Q QN:P TTN SIH H !895 SA CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
INSTL CENTRAL HEATER & A/C O O o 0
"00 LICENSED CONTRACTOR'S DECLARATION lob Description
i� 1 httcby alarm Nal I am licensed under provisiam of Chapter 9(commencing
with Sadon 7010)of Division 3 ordle Bounty and Prolsuom Code.and my Ikeme Is
din full forts and CIYWL A 133 I
j 4 Licenm Claw L1.1
LOa1C Contractor
3eQ�Q ARCHITECTS DECLARATION
C 2 t 1 undersand my plans Nall M sued as public mora
JyU
g o Liccnwd Pmfessionai
5
OWNER-BUILDER from
DECa,coma ON
f 1 hereby vnirm Nat 1 I.J.
Busi from tPr Cssion C a e:Any c Law for the
❑O fallowing reason.(Section 7011.3.Business and Profession Code:Any city m county
SV which rtqukea a P sarl,to construct.ser.Improve.demolish,m repair any structure
_Z'n prior to its issuance.also enquires the applicant for such Permit o file a signed makmenl
fie thuhculicensedpumunlmItspnevisiomofNeConvacmhLuemelaw(chapttt9 Sq.F[.Floor Area Valuation
'10
� (emnmencing wish Section 7000)of Division 3 a the Business And Professions Cede)or
that be is esempt tMaerrom and the beau far the alleged em 0.Any violation of
Sectlon 70315 by any applicant for a pumit subjects the MP icant In a CIV;1 penalty of APN Number Occupancy Type
and mom duke Gw bundled dallara(ssod).
❑i,u owrcr a(Ilr propctty.tt my unPloyaa with wage ea IIrR sok cwnpewdon,
and Pr thework,and the th Comramtlokname,raw ci fmakle(sec.IO ad,Owner Of
and enywh ons Caeca:The Canuamars License law dam sot apply n an awmr ter Required Inspections
ow.cro whonaamorimpraws.:mon,dnawho As nsackwork Hammers,through his
awn cmployva,provided that such empmsemcnw art m i as cded aroBemd fuseals.the mum If.
however.the building or Improwmmr4mid w;shm am year or completion.the —Of
buildtt will love tic burden of proving that Media tat dile Cr improve for pugoue a(
talo.).
1,as owner of the property,am exclusively contMing with licensed Con taclem to
coral.,the project(See.7044.Business AM Profeauam Cade:)The CanOacmea U.
came law deco not apply o an owmr of property who builds or Unprown themon,and
who comae%for such projects with.eamracan(s)licensed Pramual to the Cma'aa es
License law.
❑lamdem du B&P C for Nis mason
Ow. L _ 7. D.a
WORKERS COMPENSATION DECLARATION
I hereby affirm uMer penalty of perjury one of the following deck a ims,
OreOhaw lode w0i mainwin s Cerufwaaf Consent m felt-insure(a WaM1dsCompeo-
.as provided for by Section 3700 or the labor Code.for due performance of the
.
which this permit is issucrL _
❑1 have and will maintain Workers Compensation Inmrwta,as n quirtd by Sccum
3700 of she labor Cada.fa an,performance of she work(orwhic,this permit is issued.
MY Workers Cnmpeeaation Laurance carrier and Polly number are:
Carrier. Policy No.:
CERTIFICATE OF EKEMMON FROM WORKERS'
COMPENSATION INSURANCE
(Thu Mellon need not M completed if the permit is foram hundmd doll=($1001
or las)
I eerily libel in the performance of the work For which this permit is issued,l shall not
empkyanypermn in my man ,mAsnbceareaanoble"m the Worker]CompCnLdan
Laws of Cal ice.D ��QQ..//SS'+t�. QQ
Applicant C-kl a—Van,
NOTICE TO APPLICANT.IL aimr making this Cer ifieate of Emmption,you should
become subject m the Worices Compensation provisions of the labor Cods,you mow
.,Q forthwith Comply weed such provisions or this permit shall be dcemed revoked.
z CONSTRUCTION LENDING AGENCY
[=tom Ilrmhr ainrm this there uOeanslraum lending,gem m,theperfarmuaeaf
z> the work far which tw Permit k ieaea(Sec.3097,Civ.C.)
Lenders Nuns ,
=z Leaders Adreea
a
U Q 1 certify that I haw and this application and stye Nu the show information is '
I.E coact 1 agree to comply with all city and county ordinances tab Ink uwt relating to
-D U building construction.and hcmby authorise rtpreuenatives ofthu city to enter upon the
r W abow-mentioned property for impcdm purposes
6. (We)agree to an.indemnify wall kcep hapask ar the City of Cupertino against
(~ A IeabelidU.judgnums.cath.4 am.which may;n any way aeaTr &Am,And City
U in conxyuuoe Of dm granting of this Parrott.
^c APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOjl11REGygATONI
Re-roofs
Signmum of ApplicandCanlndor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future balding acupantnom or handle hmardom materiae
as defined by that Cupertino Municipal Cade,Chapter 9.12,and the HeaTN and Safely
Cade,section 23332(0)+ All roofs shall be inspected prior to any roofing material being installed.
❑Yns 0N
Will the applicant or mom building actmpaet Wa c luiPmal as devices which If a roof is installed without first obtaining an inspection,I agree to remove
I havamnm air contaminants as de6md by the Bay Arm ter Qm ILY Management all new materials for inspection.
:dol
❑Yns RfN.
I haw mad the harallousmakrWsmquirtmenss under c aPor6.95 of the Califor-
maHca"safely Cade,SCLvwts255135XD3 am125334.1 endrmmd theifthe Ndiding
does not cunendy haw a emanL that it u my mapomiNlelY to miry the oecmpeat of die
regmre a�wltiet��x m an catirramaraapaney. Signature of Applicant Date
All roof coverings to be Class':W'or better
Owner ter mNoized agmn Data
CITY OF CUPERTINO
• 6 ITEMS OF 12 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35718029 . 93
DATE ISSUED. . . . . . . : 12/04/2008
RECEIPT # . . . . . . . . . : BS000006747
REFERENCE ID # . . . : 08120039
SITE ADDRESS . . . . . : 21793 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 9, 169 . 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
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
•
Community Development
10300 Torre Avenue
✓ Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEt�TINO
Building De artment
JOB ADDRESS: PERMIT #
�r 'lk'3 61,ve Ave (-� (2003
OWNER'S NAME: ;�—L-1, sl n �, PHONE #40d--
GENERAL CONTRACTOR: Fe)-4raKr
e FAX # 408 (7 I
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
aa.'-
FURNACE/AC
I OF
WUPERTINO PERMIT APPLICATION FORM
APN # 7 / � O h I Date-
,
Buildin Address: oC
217q� 6FQ Ave,
C�
O ner'�s N1 ame: Phone#: 65 — 2
-Lti. S�1•�
Contractor: Phone #: $— �— t 7-=,Pe4bNq,,Ahce Aw
Fax #: 4o8 -9>o-6 f71
Contractor License#: Cupertino Business License#:
261331
Contact: Phone#: 69D— r I u —4 Z
C( - l l S��� Fax #:
Building Permit Info:
Elect Plumb Mech
Residential Commercial ❑
Job Description:
T.,S fall �.PMfi-a' eater `� A /C-
For
L
For Residential Installations:
Attic ❑ I" floor ❑ 2"a 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 Construction (Usage Class):
Q M
Strapped On Platform Bonded New Location Replacement
Project Size: Express Er 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.
• Revised 6/16/08
CITY OF CUPERTINO
FURNACE/AC
C OF
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.
IPGASCOM 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
i heating,cooling,absorption or
I` 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
(: n