The URL can be used to link to this page

07050133r0,Zo v i<a z �__ Qi a �aU CWF" :tea �Q(7 EFQ Y LICENSED CONTRACTOR'S DECLARAI tun 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is n full force and effect License Class Lic• # Date Contractor ARCHITECTS DECLARATION I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Section 703 1.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance. also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's Liccntse Law (Chapter 9 (commencing with Section 70[10) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and florbasis subjectts the applicged ant o a civil tolation of penalty of Section 7031.5 by any app' permit not more than five hundred dollars (5500). ❑ 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 andProfessions 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, toe 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 rcense . as owner of the property. am exclusively contracting with licensed contractors to truct the project (Sec. 7044, Business and Professions Code:) The Contractor s Li - Law docs not apply o an owner of property who builds or improves thereon, and. contracts for such projects with a contractor(s) licensed pursuant o the Contractor's nse Law.B & P C for this mason am exem t under Sec owner Date /G G ORK 'S OMPENSATION DECLARATION I hereby tiro under penalty of perjury one of the following declarations: L] 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. ❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number arc: 0 C H � a> Gla Q f]� �Dz UC mom- V. U2 :artier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) 'r less.) certify that in the performance of the work for which this permit is issued. I shall not :mploy any person in any manner so as to become subject to the W� i pensation aws of California. Date 4pplicant VOTICE TOAPPLI�after making this Certificate of Exemption, you should 3ecome subject to the Worker's Compensation provisions of the Labor Code, you must Forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 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.) Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for inspecuon purposes. (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 in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCERE;U TIONS. Signature of Api Ii Contractor o AZARDOUS MATERIALS DISCLOSURE 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)? ❑ Yes <No 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 District? ❑ Yes o 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 docs not currently have a tenant, that it is my responsibility to notify the occupant of the mouirements which must be metprior o issupce of a Certificate of Occupant'. Owner or G/ Date .IohIlcscdption 7F =Number ea Valuation AI'N Occupancy Type Required Inspections C Issued by: , Re -roofs Type of Roo' All roofs shzll be inspected prior to any roofing material being installed. If a roof is ir.stalled without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant All roof coverings to be Class "B" or better Date 8 ITEMS OF 8 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lc,t: APN ........: 356210.6.00 DATE ISSUED.......: 05/16/::007 RECEIPT #......... BS000001343 REFERENCE ID # 070501:>3 SITE ADDRESS .....: 11235 CATALINA CT SUBDIVISION ....... CITY• CUPERTINO .............. IMPACT AREA ....... OPERATOR: bethe COPY # : 1 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 176.34 --------------- 176.34 VOICE ID DESCRIPTION -------- ------------------- 301 ROUGH PLUMBING REFERENCE NUMBER VISA VOICE ID DESCRIPTION -------- - -------------------------- 303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY 502 FINAL PLUMBING ENERGY 503 FINAL MECHANICAL ENERGY 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL OWNER ............: FALK EJGENE S AND HARRIET J TR ADDRESS .......... CITY/STATE/ZIP ...: CUPERTINO CA, 95014-4737 RECEIVED FROM • " CONTRACTOR ....... , TODDNSTONEK LIC # 24700 COMPANY ..........: BAY MOUNTAIN AIR ADDRESS ..........: 125 DILLON AVE #B CITY/STATE/ZIP ...: CAMPBELL, CA 95008 TELEPHONE ........: (408)378-6375 UNIT QUANTITY AMOUNT PD -TO -DT THIS REC- NEW FEE ID --- -BAL- - ___ BENERGY ___ ---------- PERMIT FEE ---------- 1.00 34.86 0.00 0.00 34.86 10.26 0.00 0.00 BREMAIRHAN NO.UNITS 1.00 10.26 14.31 0.00 14.31 0.00 BREMFURN NO UNIT 1.00 1.00 1.20 0.00 1.20 0.00 BREMRECEPT NO. OUTLETS 5,875.00 0.60 0.00 0.60 0.00 BSEISMICRE VALUATION 1.00 38.37 0.00 38.37 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 PPERMITFEE FLAT RATE ----0_00 ------ 176.34 0.00 176.34 0.00 TOTAL PERMIT METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 176.34 --------------- 176.34 VOICE ID DESCRIPTION -------- ------------------- 301 ROUGH PLUMBING REFERENCE NUMBER VISA VOICE ID DESCRIPTION -------- - -------------------------- 303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY 502 FINAL PLUMBING ENERGY 503 FINAL MECHANICAL ENERGY 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL aCITYF CUPEkTINO CITY OF CUPERTINO FURNACE/AC PERMIT APPLICATION FORM rr,.,niiv neveloDment ,r APN # Date: _ Building Address.- ddress:1r BREMFURN 11-Z 3 s` WZ-77 MECHANICAL Owner's Name: Phone #: MECHANICAL t/ o 2 s 7-- Contractor: Phone: f�/F Y ,} Ile- 1-/o 3 "7Y-- 3 7 S License #: % U -3 S 76' Contact: Phone: Cupertin Business License #: ELECTRICAL BSEISMICRE Building Permit Info: BUILDING Bldg ❑ Elect I" Plumb ®' Mech G - Job Description: EPERMITFEE /zP 6 4 Residential- Commercial ❑ MPERMITFEE For Residential Inst llations: MECHANICAL Attic ❑. 1" floor 2nd floor � Plumbi:ig Permit Issue Adhere to min set back requirement BPERMFEE For Commercial Installations: BUILDING replacement same weight ❑ Additional weight (structural calcs) ❑ Plan Cr eck Fee Structural Calculations required for new installation ❑ BPGAS New installation Planning Approval Required ❑ PLUMBING Cost of Project/Type of Construction: e % Occupancy group: �- Strapped ❑ On Platform 0— Bonded ❑ Sq.Ft. Floor Area: New Location 151- Replacement Qty. if Applicable Fee ID Fee Descrintion FeP (;rnnn BENERGY Energy BUILDING BREMFURN Furnace'- MECHANICAL BREMACOVER A/C Unit > 10,000 cfin MECHANICAL BREMAIRHAN A/C Units <= 10, 000 cfin MECHANICAL / BREMRECEPT Recptl, Switch & Outlets ELECTRICAL BSEISMICRE Seismic; Fee Res BUILDING BSEISMICOM Seismi4; Commercial BUILIDNG EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbi:ig Permit Issue PLUMBING BPERMFEE Bldg Pcrmit Fees BUILDING BPLANCHK Plan Cr eck Fee BUILDING BPGAS Gas Pi ing System Fee PLUMBING BUSLIC Busine:,s License BUILDING