08120132 CITY OF CUPERTINOt, 'fs
BUILDING DIVIFION PERMIT =�.CUNTRACTORINFURMATION '
BUILDING ADDRESS: PERMIT NO.
19915 PRICE AVE AAA 'FURNACE & AIR 0212nj �?.
OWNER'S NAME: CONDITIONING PERMIT ISSUE DATE
clilpl i:42 STGNS AVE;
p SA CONTROLNO.
ARCHf1ECT/ENGINEER: BUILDING PERMIT INFO
REPLACE FURNACE 100, 000 BTU BLDG ELECT PLUMB � MECH
l� O O O
o$ LICENSEDCONfRACIORS DECLARATION lob Description
w 1 hereby affirm Nal I am licensed under provisions of Chapter 9(commencing
with Session 7000)of Division 3 of the Budnun and Professions Code.and my license is
M in full forand etf 6 t p
ZLiccnac a Clss. (' C G Lk2/.N '
O Dau /T�Lj (�,�Conlncur
en p rJ' ARCHITECTS DECLARATION
?W U 1 understand my plans shall be used re
as public cords
y.
;6
Qy Licensed Professional
OWNER-BUILDER DECLARATION
I hereby aTBrm
that 1 am exempt form the Communes License Law for the
no following mason.(Section 1 W 1.5.Business and Professions Code:Any city or county
$ which requires a permit in commet.alar,improve,demolish,in repair any structure
-Z6 One,in its isnona,alsa requires tbeapplicam for such permit to flleaslgned elaNmem
that he is licensed pursuant to Nlila
e previsions of the Contractor's cense Law(Chapter 9 Sq.Ft. Floor Area Valuation
[�m (commencing with Section T00))of Division 3 of the Business and Profusions Cody or
Nn w is exempt therefrom ard the basis for the alleged eaemptim.Any violation of
Section 7031.5 by arty applicant fm a permit subjects be applicant 10 a civil Penalty,of ApN ft. Number Occu ane
oat moa man ve hundred dorm00)
s(55 . P y Type
i,as owner of tie property,in my employers with wages as nbeh tale eampeva0on,
will de the work and the swcmm is not Intended or offend for ache(Sec.TOas,Busims
and Professions Code:The Condacthrs License Law does not apply to an owner of Required Inspections
property who builds in impmveadumon,and whodosswch wort hiruelfar though his
comemployess,provided that such impmvemenu are not intended oroReaed(nasal.IL
however.the building or improvement is sold within ane year of completion,the owner.
builder will have the burden of moving mat he did not build or improve for purpose of
sal:.).
1,as owner of the property.am=elusively conducting with licensed Continuum le
construct the projen(Sec TOas.Business and Pmfetsiau Code:)The Conducts?.Li.
cease Law does our apply to an owwr of prepeny who builds or improves thno wn,and,
who Contracts for such projects with a conuacur(s)licensed puruant us the Contrxae?s
License law.
Lamexzmqumder See ,B&PCrorthu.a
Owner Dau
KFJATI
WORt'S COMPENSATION DECLARATION
1 hereby andm under pcwity of perjury oro at the fallowing d mmendorms:
❑1 have and will maintain aCcrtifrute of Coucnt to self-Insure for Wortets Compen-
sation,as previdW fix by Section 3700 of das Labor Code.for th<performance of the
wmlr for which mu permit is issued
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the labor Code,for the performance of the work for which this permit is issued
My Workers compensation Intifada carrier and Policy number am: � � /
cion.'.'51&
Z /V i Polity Na.:�L�va r.rr j,'GJ
CERTIF&I EXEM ION FROM WORKERS
COMPENSATION INSURANCE
QTuxction reed not he completed flux Permit is forme hundred dollars(SIM)
no leu)
I certify mat in the performance of the work far which this Omnil is issued.l shall not
employ any person in soy manner an as u become object to tit Workers'Compensation
laws of California.Date
Applicant
NOTICE TO APPLICANT:If,slur making mu Ci niricau of Exemption,you should
become subject in the Workers Compensation previsions of dmc labor Code.you mine
.,O roMwith comply with such provisions m this permit sball be deemed revoked.
'Z� CONSTRUCTION LENDING AGENCY
F.r Imfr
rehyannthatft.iiscom urcim.ImHng.gmyforft rrar ..f
C me work for which this Permit is issued(Sec.3097,Co.C.)
GA lender's Name
Z lende?s Address
U Q 1 unify that 1 have mad this application and sou than the above information is
IT. F comes,I agree to comply with all city and county eminences and sum laws relating in
,0U building Convection.and hereby sunburn representatives of this city to trout upon the
shove mcnuomd property for inspection purposes
Hy (We)agree to save,indemnify and keep harmless the City of Cupcnino against
liabilities,judgments.ensu and C.,.,which may In any way..against said Cil,
U Z in eanuquence of the granting of this permit. 2
m-' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOY CE REGULATIONS.
/Z 'L L t Re-roofs
Signature of ApplicanuCantur;qccerr Dau
HAZL US MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant sure or handle ha>allous material
as dcOncd by de Cu mnino Municipal Code.Chapter 9.12.and rhe Health and Safety
Code.Section 25532(4)1eN� All roofs shall be inspected prior to any roofing material being installed.
res N.
Will rite applicant or rumor Wilding oaupmt use equipment or Jcvim which If a roof is installed without first obtaining an inspection,I agree to remove
emit hitmenus air contaminants as de it by the Bay Area Air Quality Management all new materials for inspection.
Diavinl
Oyu
1 have hu
mail me vardmmaunalsrequircmenu under Chapur6.95 of 02(Califor-
nu FkaIN&Safety GaM.Sc voru25505,25511 and 255X.1 uMcrsund JdsifNc building
dMa not currently haw a muni that it Y my responsibility or notify ft 0.Cowl of the
reggimments wmer must Im mm poor to imunme of a Cmiicam of Occupancy. Signature of Applicant Date
O:J.wner or aunboh� mcd agent i - .✓ 1 'LL Date L p All roof coverings to be Class'W'or better
O � "
+ Community Development
4
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
OCUPEkTINO
Building De artment
JOB ADDRESS: PERM
/c /i
OWNS 'S NAME: PHONE # p - o 0
GENERAL CO OR: ZAe
C FAX #
I am not using any subcontractors: L -.12 D/
Signature Date
Please check applicable subcontractors and complete the followinginformation:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
eLinoleum/ 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
• 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sea: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36905043 . 00
DATE ISSUED. . . . . . . : 12/22/2008
RECEIPT # . . . . . . . . . : BS000006873
REFERENCE ID # . . . : 08120132
SITE ADDRESS . . . . . : 19915 PRICE AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : MICHELLE CHIN
ADDRESS . . . . . . . . . . : 19915 PRICE AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : JIM RANDO
CONTRACTOR . . . . . . . : RANDO, JIM LIC # 8050
. COMPANY . . . . . . . . . . : AAA FURNACE & AIR CONDITIONING
ADDRESS . . . . . . . . . . : 1712 STONE AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
• TELEPHONE . . . . . . . . : (408) 293-4717
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------ --------- --- --- ----------
1BSEISMICR VALUATION 3 , 100 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
IMPERMITFE 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 visa
---------------
TOTAL RECEIPT 224 . 85
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
---------------------------- ----------------------------
505
----- ------- -
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
•
CITY OF CUPERTINO
FURNACE/AC
CUPEkTiNO PERMIT APPLICATION FORM
APN # Date:
Building Address:
/
Owner's Name: Phone #:
04 :G ?v4-
Contractor: Phone #:
"epH/Ao /a.q C / r Fax #:
Contractor License #: Cupertino Business License#:
Contact: Phone #:
J 71e;7
Fax #:
Building Permit Info:
Elect Plumb ET� Mech
. Residential Commercial
Job Description:
ri
For Residential Installations:
Attic ❑ ls` 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: 3100 ,gg Type of Construction (Usage Class):
�,/ 0
Strapped D On Platform El Bonded D New Location Replacement
Project Size: Express ❑ Standard ❑ Large ❑ Major ❑
Valuation:
3 /a� �o
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 6/16/68
CITY OF CUPERTINO
G� FURNACE/AC
I OF
CUPERTINO 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.
IMCSUSHTR 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
1BPGAS For each gas piping system of 5 or P
more per outlet.
IMCAPPVNT 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
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.
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