07060029 CITE'OF CUPERTINO PERMIT
BUILDING MISION PERMIT
PERMIT NO.
1T E
""'Jl'6SS4AAA FUR 1ACE AIR 07060029
eeNBa-Ti113 l 4 MIRA VISTA AVE &f PERMrr LSSUE DATE
OWNER'S NAME:
SUMNER ROBERT B AND BETTY M 1712 Sr'ONE AVE 06/05/2007
SANITARY NO. CONTROL NO.
,NE:
(408) 29;-4717
BUILDING PERMIT INFO
ARCHITEC(ENGINEER: BLDG ELECT PLUMB MECH
0 0 a a
p p LICENSED CONTRACTOR'S DECLARATION Job Description
u
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
z� with Section 7000)of Division 3 of the Business and Professions Code,and my license is REPLACE FURNACE 80, 000 BTU & DUCT WORK, ADD A/C.
;<a. C:
in full force and of /1
t
v�z License Class `- Lic.#
G pare — Contractor
J
ARCHITECTS DECL R
i a a I understand my plans shall be used as public records
>aV
LLH Licensed Professional
o a OWNER-BUILDER DECLARATION
3 a I hereby affirm that 1 am exempt from the Contractor's License Law for the
:p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct.alter,improve,demolish,or repair any structure
H prior to its issuance,also requires the applicant for such permit to file a signed statementValuation
?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 >q.F[.Floor Area 1 O O O 0
H (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 5 7 0 2 0 2.2:M Number Occupancy Type
not more than five hundred dollars($500).
0 I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
0 I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 I have and will maintain a Certificate of Consent to self-insure for worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
0 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 insu rice carrier and Policy number ate:
Carrier: Policy No.: Z9 11
CE TIFIC O EXEMPTION FROM ORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
i certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of CaliforbDate
Applicam JJ 11 ��A — 16.
NOTICE TOOXi PPLI ANT:If,of making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
hamn I hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lenders Name
z Lender's Address
U O 1 certify that I have read this application and state that the above information is
U. correct.1 agree to comply with all city and county ordinances and state laws relating to
0 U building Construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
C3, (We)agree to save,indemnify and keep harmless the City of Cupertino against ,
liabilities,judgments,costs and expenses which may in any way accrue against said City
U z in consequence of the granting of this permit. Date G �
�. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
Re-roofs
Signature of Applicant/Contractor Data
HAZARDOUS MATERIALS DISCLOSURE Type of B.00f
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
fi
0Yes If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Yeses
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safcty Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
rcyu' mems which must be met prior to issuance of a Certificate of Occupancy. Signature Of Applicant
7Date
'v' All roof coverings to be Class"B"or better
wncr or authorized alcrit Date
CITY OF CUPERTINO
8 ITEMS OF 8 PERMIT' RECEIPT OPERATOR: suew
COPY # 1
Sec: Twp: Rng: Sub: Bll:: Lot:
APN 35''02022 . 00
DATE ISSUED. . . . . . . : 06,05/2007
RECEIPT # . . . . . . . . . BS000001547
REFERENCE ID # . . - : 07060029
SITE ADDRESS . . . . . : 10. 14 MIRA VISTA AVE
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER SUT'INER ROBERT B AND BETTY M
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2745
RECEIVED FROM . . . . : JIN RANDO
CONTRACTOR . . . . . . . : RANDO, JIM LIC # 8050
COMPANY AAA FURNACE & AIR CONDITIONING
ADDRESS . . . . . . . . . . : 17:_2 STONE AVE
CITY/STATE/ZIP . . . : SAIT JOSE, CA 95125
TELEPHONE (408) 293-4717
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- - --------- ---------- ---------- ----------
BENERGY PERMIT FEE 1. 00 34 . 86 0 . 00 34 . 86 0 . 00
BREMAIRHAN NO.UNITS 1. 00 10 .26 0 . 00 10 .26 0 . 00
BREMFURN NO UNIT 1 . 00 14 . 31 0 .00 14 .31 0 . 00
BREMRECEPT NO. OUTLETS 1 .00 1 .20 0 .00 1.20 0 .00
BSEISMICRE VALUATION 10, 000 .00 1 . 00 0 .00 1. 00 0 .00
EPERMITFEE FLAT RATE 1. 00 38 .37 0 .00 38 . 37 0. 00
MPERMITFEE FLAT RATE 1 . 00 38 .37 0 . 00 38 .37 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 .37 0 . 00 38 .37 0 . 00
- --------- ---------- ---------- ----------
TOTAL PERMIT 176 . 74 0 .00 176 . 74 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 176 . 74 VISA
---------------
TOTAL RECEIPT 176 . 74
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL 508 FINAL MECHANICAL