07050129 77777
CITY OF CUPERTINO
BUILDING DIVISION' PERMIT G3 `RACTtTR IEORMATION:
PERMIT NO.
BUILD.{Nfr�f3D6� IN FOOTHILL BLVD VALLEY I[EATING & COOLING 07050129
l U G(� N PERMIT ISSUE DATE
OWNER'S NAME:
AZEVEDO EDWARD J AND JULIA 1171 N E: TH ST 05/15/2007
JN
SANITARY NO. CONTROL NO.
(408) 29�:-6290
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
10Zo LICENSED CONTRACTOR'S DECLARATION Job Description
UP 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z iW with Section 7000)of Division 3 of the Business andProfessions Code,and my license is INSTALL A/C UNIT AT REAR
Hin full force and effect 2 S
Z License CI Lie
3 t—uwi Date conuww
A CHITECTS DECLAR ON
a-r 1 understand my plans shall be used as public records
V
)y
t n.H Licensed Professional
a OWNER-BUILDER DECLARATION
1 hereby affirm that I 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
9;- prior to its issuance,also requires the applicant for such permit to rile a signed statement e Ft.Floor Area Valuation
a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q $5000
EEC$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and time 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 2 613 0 6£3:'t7 t1' Number Occupancy Type
not more than five hundred dollars($500).
❑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.70",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 Contractors 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 mason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Workcfs 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 Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Cartier. 1W&A&3,LT%k Policy No.:?."a(a�J�Z.'
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 Workers'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
Z forthwith comply with such provisions or this permit shall be deemed revoked.
O CONSTRUCTION LENDING AGENCY
H.�+ I hereby affirm that there is a consuuctian lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
Z Lender's Address
U C I certify that I have read this application and state that the above information is
;.T. r c correct.1 agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorize representatives of this city to enter upon the
W
above-mentioned properly for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
o.4 t) liabilities,judgments,toss and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. Date S— le—f"
Jf' Ti7
►-. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOW INT Issued by:
SOUR LA'n
� Re-roofs .�
Signature of ApplicintRWtillittor vote Type Of R)Of
H DOUS MATERIALS DISCLOSURE yp
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.
C3 Yes 18no
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new in iterials for inspection.
District?
❑Yes o
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Cade,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
requtrcm tut be prior to issuance of a Certificate ofOccu ry. 1 Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner or authorized a n D
CITY OF CUPERTINO
7 ITEMS OF 28 PERMIT RECEIPT OPERATOR: suew
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 32613068 .00
DATE ISSUED. . . . . . . : 05/15/2007
RECEIPT #. . . . . . . . . BS000001339
REFERENCE ID # . . . : 07050129
SITE ADDRESS . . . . . : 10526 N FOOTHILL BLVD
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : AZEVEDO EDWARD J AND JULIA TRU
ADDRESS . . . . . . . . . . .
CITY/STATE/ZIP . . . : ORANGEVALE CA, 95662
RECEIVED FROM . . . . : THIMH NGUYEN
CONTRACTOR . . . . . . . : ATKINSON, THOMAS LIC # 141
COMPANY . . . . . . . . . . : VALLEY HEATING & COOLING
ADDRESS . . . . . . . . . . : 1171 N 4 TH ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95112
TELEPHONE . . . . . . . . : (408) 294-6290
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
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
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL 508 FINAL MECHANICAL
CITY OF CUPERTINO
#. IJ�� .CE�AC
CUPEkTINO PERMIT APPLICATION FORM 07050/'A
_XN# Date:
3,�4
Building Address:
(r)621 J5
Ow er's Name: Phone#:
LOIIII-dC�01;
F I�onc . License N
ccs S 2
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect Pl Amb Mech
Job Description:
I�t�qu..Q Tln� oar A-e, Co o uA7
Residential Commercial ❑
For Residential Installations:
Attic 11. 1St floor a 2nd floor�
Adhere to min set back requirement
For Commercial Installations:
,placement same weight E] Additional weight (stnictural calcs) ❑
structural Calculations required for new installation Cl
New installation Planning Approval Required ❑
Cost of Project: Type of Cons cti on: Occupancy group:
.S55oo C> el
Strapped ❑ On Platform Bonded Er Sq.Ft. Floor Area:
New Location RSplacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
/ BENERGY norgy BUILDING
BREMFURN Fuz pace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfin MECHANICAL
BREMAIRHAN A/C'Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Re;ptl, Switch & Outlets ELECTRICAL
BSEISMICR.E Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
/ PPERMTTFEE P1Lmbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BPGAS Gas Piping System Fee PLUMBING
BUILDING
BUSLIC Business License
sum; Community Development
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: FAX #
I am not using any subcontractors:
Si€nature Date
Please check applicable subcontractors and com lete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
V"" Heating j, $S
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Y 0 r,01,0,�2�e
'8V F,- -
(!�Eer ontractor Signature l4ate