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07050128 CITY OF CUPERTINO BUILDING DIVISION PERMIT PERMIT NO. BUILD,(IJ);�pIZD�ES$:_ FOOTHILL BLVD VALLEY HEATING & COOLING 07050128 l�J 7 l N PERMIT ISSUE DATE OWNER'S NAME: MONTGOMERY DEE ANN 1171 N 4 TH ST 05/15/2007 SANITARY NO. CONTROL NO. )NE: (408) 29,1-6290 BUILDING PERMIT INFO ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH 0 0 p LICENSED CONTRACTOR'S DECLARATION Job 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 INSTALL A/C UNIT IN REAR H in full force and effect. ? License CI Lic•M E=W ARCHITECTSConDECLARATION a< I understand my plans shall he used as public records )qU o ml- Licensed Professional y OWNER-BUILDER DECLARATION 1 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 u z} prior to its issuance,also requires the applicant for such permit to rile a signed statement ,. Valuation e that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 >q.Ft.Floor Area 5 O O 0 YF (commencing with Section 7000)of Division 3 of thc Business and Professions Codc)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 of3 2 613 0 6 7 �Number Occupancy Type not more than five hundred dollars(5500). ❑1,as owner of the property,or my employees with wages as thew 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 docs 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. ❑1 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: ❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compen- sation,as provided for by Section 3700 of the Labor Code•for the performance of the work for which this permit is issued. ❑I 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 Insurance carrier and Policy number are: Cartier 26M<<t PolicyNo.: 0 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,1 shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Workers Compensation provisions of the Labor Code,you must 0 forthwith comply with such provisions or this permit shall be deemed revoked. Z " CONSTRUCTION LENDING AGENCY F~C/) I hereby affirm that there is a construction lending agency for the performance of C4> the work for which this permit is issued(Sec.3097,Civ.C.) W A Lender's Name az Lenders Address U Q 1 certify that I have read this application and state that the above information is (L correct.I agree to comply with all city and county ordinances and slate laws relating to Jbuilding construction,and hereby authorize representatives or this city to enter upon the U above-mentioned property for inspection 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 _ V Z in consequence of the granting of this permit. Date /1 `&_7 ►-r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SOUR Re-roofs Signature afApplr n for Doth T of Roof H DOUS MATERIALS DISCLOSURE Type 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 ;hall be inspected prior to any roofing material being installed. [3 Yes o Will the applicant or future building occupant use equipment or devices which If a roof i;installed without first obtaining an inspection,I agree to remove - emit hazardous air contaminants defined by the Bay Arca Air Quality Management all new materials for inspection. District? E]Ycs Nu I have read the hazardous materials requirements under Chapter 6.95 of thc 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 require wh* oat to issuance or aGxtiricateofoc Signature of Applicant Date .11 1" 4715707 All roof coverings to be Class"B"or better Owncr or authorized agentEtta CITY OF CUPERTINO 7 ITEMS OF 28 PERMIT RECEIPT OPERATOR: suew COPY # 1 Sec: Twp: Rng: Sub: Blk : Lot: APN . . . . . . . . : 32613067. 00 DATE ISSUED. . . . . . . : 05/15/2007 RECEIPT #. . . . . . . . . BSC00001339 REFERENCE ID # . . . 07C50128 SITE ADDRESS . . . . . : 10516 N FOOTHILL BLVD SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : MOISTGOMERY DEE ANN ADDRESS . . . . . . . . . . . CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-0803 RECEIVED FROM . . . . : THINH NGUYEN CONTRACTOR . . . . . . . : ATKINSON, THOMAS LIC # 141 COMPANY . . . . . . . . . . : VALLEY HEATING & COOLING ADDRESS . . . . . . . . . . : llil N 4 TH ST CITY/STATE/ZIP . . . : SAIS JOSE, CA 95112 TELEPHONE . . . . . . . . : (4C8) 294-6290 FEE ID UNIT QUANTITY IMOUNT 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 BREMRECEPT NO. OUTLETS 1.00 1.20 0 .00 1.20 0 .00 BSEISMICRE VALUATION 5, 000 .00 0.50 0 .00 0 .50 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 161. 93 0 .00 161 . 93 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 647.72 VISA --------------- TOTAL RECEIPT 647.72 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL 508 FINAL MECHANICAL CITY OF CUPERTINO 31F'� �` JR A E ACUPi�TINO PERMIT APPLICATION FORM 070 50J,,?8 __t'N # Date: Bu/i'l�diinng Address: l ` Q O ner5 s Name: Phone#: C-�I�o� CQ) 2.c5 told `(tirlLt-dC"oi.. '�1n71f': l,IC 17�C : VAI .Z. 7- Contact: Phone: Cupertino Business License#: 0A L) bt, 2 Building Permit Info: Bldg ❑ Elect PI amb Mech Job Description: OC. Itl Residential ❑ Commercial ❑ For Residential Instodlations: Attic El. I" floor 2nd floor F1 Adhere to min set back requirement For Commercial Installations: placement same weight ❑ Additional weight (stnictural talcs) ❑ structural Calculations required for new installation D New installation Planning Approval Required ❑ Cost of Project: Type of Construct:on: Occupant oup- Strapped El On Platform Bonded ' Sq.Ft. Floor Area: New Location ❑ Replacement Qty. if Applicable Fee ID Fee Description Fee Group BENERGY Enorgy BUILDING BREMFURN Fuinace MECHANICAL BREMACOVER A/C Unit> 10,000 cfin MECHANICAL BREMAIRHAN AUnits <= 10, 000 cfin MECHANICAL /(: BREMRECEPT Re;ptl, Switch & Outlets ELECTRICAL BSEISMICRE Seismic Fee Res BUILDING BSEISMICOM Seismic Commercial BUILIDNG EPERMITFEE El cc Permit Issuance ELECTRICAL MPERMITFEE Me ch Permit Issuance MECHANICAL PPERMITFEE P1Lmbing Permit Issue PLUMBING BPERMFEE Blclg Permit Fees BUILDING BPLANCHK Plan Check Fee BUILDING BPGAS Gas Piping System Fee PLUMBING BUSLIC Business License BUILDING Community Development g, 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 `;UPEkTIN0 Building Department JOB ADDRESS: PERMIT# OWNER'S NAME: PHONE # GENERAL CONTRACTOR: AX # 1-I �q I am not using any subcontractors: Si;mature 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 D Own C ntractor Signature date