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07030076
CITY OF CUPERTINO BUI DING DIVISION PERMIT � � ® ` IFC}RMTI®N . . BUILDING ADDRESS: PERMIT NO. 20045 DEPALMA LA TBD - TO BE DETERMINED 07030076 PERMIT ISSUE DATE OWNER'S NAME: BILL RASSIHUR 03/12/2007 SANITARY NO. CONTROL NO. )NE: BUILDING PERMIT INFO ARCHITECT/ENGINEER: REPLAC�-, FURNACE, ADD A/C BLDG ELECT PLUMB MECH i p a LICENSED CONTRACTOR'S DECLARATION Ob Description v 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 t<H in full force and cf t r ? License Class Lic.ff ir Con F Date ARCHITECTS DECLARATION 7 < 1 understand my plans shall be used as public records >yU u.F Licensed Professional y OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the p C following reason.(Section 7031.5,Business and Professions Code:Any city or county `t Pi which requires a permit to construct,alter,improve,demolish,or repair any structure Z�y prior to its issuance,also requires the applicant for such permit to rile a signed statement rea Valuation _ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor A e.( (commencing with Section 7000)of Division 3 of the Business and Professions Code)or i 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 APN Number Occupancy Type not more than five hundred dollars(2500). ❑1,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.). ❑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. ❑I am exempt under Sea B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: - - ❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compcn- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy n her''arey- 2� Carriers`W C 6Policy No.: ENCS �7L75� CERTIFICATE OF EXEMPTION FROM WORKERS' 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,I shall not employ any person in any manner so as to become subject to the Workcrs'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after 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 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 Lender's Namc az Lender's Address U 0 I certify that 1 have read this application and state that the above informatiun is correct.1 agree to comply with all city and county ordinances and state laws relating to ,rJ U building construction,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes. CL (We)agree to save,indemnify and keep harmless the City of Cupertino against �y liabilities,judgments,costs and expenses which may in any way accrue against said City U 2 in consequence of the granting of this permit. Date APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b) SOUR EGULATIO 3A z!Lo 7 Re-roofs Signature of Applicant/Contractor Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupantstorc 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. ❑Yes 1211° If a roof .s 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 r.laterials for inspection. District? ,_, ❑Yes 10< I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety 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 rcyui nts which myst bc.mryprior to issuance of a Ccruficatc of OccuP�nc7. Signature of Applicant Date i7Y' 6� All roof coverings to be Class"B"or better Owner or authorized agent Date CITY OF CUPERTINO z `U NAC AC CUPEkTINO PERMIT APPLICATION FORM p�©.3oo76 APN# Date: /v/ l r 3�r Building Address: LA 00 Owner's Name: Phone� %� -� R33 �t I Contractor: Phone: License#: u9 tc C 20 Contact: Phone: Cupertino Business License#: 44A 690 oz�� Building Permit Info: Bldg ❑ Elect F'lumb Mech Job Description: 4 a." &G Residential Commercial ❑ For Residential Installations: Attic ❑ 1" floor, 2nd floor❑ Adhere to min set back requirement For Commercial Installations: replacement same weight ❑ Additional weight (stuctural talcs) ❑ Structural Calculations required for new installation New installation Planning Approval Required ❑ Cost of Project: Type of Construction: Occupancy group: V2,6 t% - - D Strapped ❑ On Platform A Bonded rSq.Ft. Floor Area: New Location Replacement Qty. if Applicable Fee ID Fee Description Fee Group BENERGY Energy BUILDING BREMFURN Fumace MECHANICAL BREMACOVER A'C Unit> 10,000 cfin MECHANICAL BREMAIRHAN A'C Units<= 10, 000 cfm MECHANICAL BREMRECEPT Recptl, Switch & Outlets ELECTRICAL BSEISMICRE S1;ismic Fee Res BUILDING BSEISMICOM S,;ismic Commercial BUILIDNG EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMITFEE 1V ech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPLANCHK P:an Check Fee BUILDING BPGAS Gas Piping System Fee PLUMBING BUSLIC Business License BUILDING CITY OF CUPERTINO 9 ITEMS OF 9 PERMIT RECEIPT OPERATOR: bethe COPY # 1 Sec: Twp: Rng: Sub: Bl}:. Lot : APN . . . . . . . . : 36932056 . 00 DATE ISSUED. . . . . . . : 03i'12/2007 RECEIPT #. . . . . . • . . : BS000000665 REFERENCE ID # . . . : 07030076 SITE ADDRESS . . . . . : 20045 DEPALMA LA SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : BILL RASSIHUR ADDRESS . . . . . . . . . . . CITY/STATE/ZIP . . . : , RECEIVED FROM . . . . : RECEIPT INTERFACE CONTRACTOR . . . . . . . : TBI) - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBI) - TO BE DETERMINED ADDRESS . . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . . 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 BPGAS OULETS 1 .00 5.40 0.00 5 .40 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 BSEISMICRE VALUATION 11, 264 .00 1.20 0 .00 1.20 0. 00 BUSLIC FLAT RATE 1.00 107.00 0 .00 107.00 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 288.14 0 .00 288.14 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 288.14 visa --------------- TOTAL RECEIPT 288.14 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY 505 FINAL ELECTRICAL Community Development 10300 Torre Avenue ' Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 UPEKTINO Building Department JOB ADDRESPERMIT # -1200�:5 �c�,lw�a ISA D ? 070(0"7 6/ OWNER'S NAME: X" PHONE # 4VS 99 012. GENERAL CONTRACTOR: `v FAX # (,sv pa S I am not using any subcontractors: S& /v 7 Signature Date Please check applicable subcontractors and co m lete the following information: SUBCONTRAC'T'OR 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 x`42 0� Owner/Contractor Signature Date