07050271 CITY OF CUPERTINO ERMIT
BUILDING DIVISION PF,�vlj j
PERMIT NO.
BUILq[Ijr,�I�DgEs 07050271 IA CAMINO CT AAA FURNACE & AIR
PERMIT ISSUE DATE
OWNER'S NAME:
BERRY HAROLD E AND BEVERLY M 1712 STONE AVE 05/29/2007
SANITARY NO. CONTROL NO.
ME:
(408) 29:-4717
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
lwz0 0 0
pO LICENSED CONTRACTOR'S DECLARATION Job Description
3 U C I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z m with Section 7000)of Division 3 of the Business and Professions Code,and my license is REPLACE FURNACE 90, 000 BTU, A/C 4 TON ADD 1 DUCT.
t=y in full force and ofac
rn 2 License CILic.# he 21
F w
D. A C ITE,
DFCContractoLAR G�
i a<I understand my plans shall be used as public records lIv
7aU
'
U.ti Licensed Professional
m OWNER-BUILDER DECLARATION
> 1 hereby affirm that 1 am exempt from the Contractors License Law for the
00 following reason.(Section 7031.5.Business and Professions Code:Any city or county
p
0.{i4 which requires a permit to construct,alter,improve,demolish,or repair any structure
Z} prior to its issuance,also requires the applicant for such permit to file a signed statement
Sq.t Ft.Floor Area Valuation
_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 $9350
F (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 ,ji Number Occupancy Type
not more than five hundred dollars(5500). 3264600( .
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 Contractors 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.).
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 U.
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 contractors
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:
❑I 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.
0 I 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 Workers Compen ation Insurance carrier and Policy number are:
. f _
Cartier. Policy No.;
TIFI A (FMP77ON FROM ORKERT
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc 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 Ccnificatc of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
z" CONSTRUCTION LENDING AGENCY
Er►�-+ I hereby affirm that there is a construction lending agency for the performance of
(Y> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
0. Lender's Address
V C I certify that I have read this application and state that the above information is
LL►- 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
U above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
of iz 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
r-" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOU
ER TIONS.
/�.�..,�,�� d.1-�9'/% Re-roofs
sslgnature " ea" for DaldV
e of R)of
HAZARDOUS MATERIALS DISCLOSURE Typ
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.
Cl Yes No
Will the applicant o 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 contami ants as defined by the Bay Area Air Quality Management all new m iterials for inspection.
District?
0 YesNu
1 have read the hazard s 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
rcqui cnts which m be met prior to issuance of a Certificate of Occupancy. Signature of Applicant Date
All roof coverings to be Class"B"or better
w er or aut.rued agent are
CITY OF CUPERTINO
8 ITEMS OF 16 PERMIT RECEIPT OPERATOR: suew
COPY # 1
Sec : Twp: Rng: Sub: Blk : Lot:
APN . . . . . . . . : 32646009. 00
DATE ISSUED. . . . . . . : 05/29/2007
RECEIPT #. . . . . . . . . BS000001486
REFERENCE ID # . . . : 07050271
SITE ADDRESS . . . . . : 22184 VIA CAMINO CT
SUBDIVISION . . . . . .
CITY CUFERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : BERRY HAROLD E AND BEVERLY M
ADDRESS
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1032
RECEIVED FROM . . . . : JIN RANDO
CONTRACTOR . . . . . . . : RANDO, JIM LIC # 8050
COMPANY . . . . . . . . . . : AAP FURNACE & AIR CONDITIONING
ADDRESS . . . . . . . . . . : 1712 STONE AVE
CITY/STATE/ZIP . . . : SAE 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 9, 350 . 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 353 .28 VISA
---------------
TOTAL RECEIPT 353 .28
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL 508 FINAL MECHANICAL
CITY OF CUPERTINO
LT
WF
FURNACE/AC
CUPEI�TINO PERMIT APPLICATION FORM 7�5`�� --7�
APN# y6 �b Date:
Building Address:
O I? A
Owner's Name: Phone#:
/_/4 -/ -11 ----- - - ------ -
Contractor: Phone: License 9:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect Plumb �� Mech
Job Description:
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1 s` floor a 2nd floor
Adhere to min set back requiremen
For Commercial Installations:
_eplacement same weight ❑ Additional weight(structural talcs) ❑
Structural Calculations required for new installation
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: Occupancy group:
g 30 A2P V�-/ C�
Strapped r ❑ On Platform Bonded 0 Sq.Ft. Floor Area:
New Location Replacement
Qty. if
Applicable Fee ID Fee Description Fee Grou
BENERGY Er iergy BUILDING
gREMFURN Furnace MECHANICAL
BREMACOVER A'C Unit> 10,000 cfin MECHANICAL
BREMAIRHAN A'C Units<= 10, 000 efm MECHANICAL
BREMRECEPT R-,cptl, Switch& Outlets ELECTRICAL
BSEISMICRE Soismic Fee Res BUILDING
BSEISMICOM Soismic Commercial BUILIDNG
EPERMITFEE E:ec Permit Issuance ELECTRICAL
MPERMITFEE M ech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE B'.dg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BPGAS Gas Piping System Fee PLUMBING
BUILDING
BUSLIC Business License
Community Development
10300 Torre Avenue
=yam° Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
"UPE�TINO
Building Department
JOB ADDRESS: PERMIT #
IF o`7
OWNER'S NAME: L PHONE # �-
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
Signature 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 ,ovv ,a
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date