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07050007 CITY OF CUPERTINO BUILDING DIVISION PERMIT �1�TR� G ('�RAN OR BUILDING ADDRESS: PERMIT NO. 11 845 UPLAND WAY AAA FU AIRA OWNER'S NAME: CONDITIONING -NtAKLAN 1 /12 STONE AVE SO@TA&_W.2 0 0 7 CONTROL NO. ABUILDING PERMIT INFO RCHITECTlENGINEER: BLDG ELECT PLUMB MECH 0 LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing w with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and cec. :L Lic.# REPLACE FURNACE 90, 000 BTU, ADD A/C 3 TON License Clan o Date — —10Q Contractor ARCHITECTS DECLARA 1 I understand my plans shall be used as public records r' Licensed Professional I a OWNER-BUILDER DECLARATION � 1 hereby affirm that I am exempt from the Contractor's License Law for the j Oy following reason.(Section 7031.5,Business and Professions Code:Any city or county ti 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 o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation $ (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 APN Number Occupancy Type not more than five hundred dollars($500). ❑I,as owner of the property,or my employees with wages as their sole compensation, 36603067 . 00 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 9 P 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.). ❑I,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 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: have and will maintain a Certificate of Consent to self-insure for Worker's Compen- w ion,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 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 arc. Cartier. 4-VI Policy No.: 7 J(6 1W D 6 CEIMFICATE OF EXEMPTION FROM ORKERS' 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. 0 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.) Q Lender's Name z Lender's Address 0 1 certify that I have read this application and state that the above information is t " correct.1 agree to comply with all city and county ordinances and state laws relating to Vbuilding construction,and hereby authorize representatives of this city to enter upon the U above-mentioned property for inspection purposes. a (We)agree to save,indemnify and keep harmless the City of Cupertino against t/) liabilities,judgments,costs and expenses which may in any way accrue against said City Z in consequence of the granting of this permit. Date �+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SOUR E REGULATIONS. Atow 49f'' Re-roofs Signature of ppli Contractor re HAZARDO S MATERIALS DISCLOSURE Type of Roof 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 shall be inspected prior to any roofing material being installed. ❑Yes 9 Will the applicant o future building occupant use equipment or Jcviccs which If a roof is installed without first obtaining an inspection,I agree to remove hazardous air contaminants as defined by the Bay Area Air Quality Management all new mi,terials for inspection. .suict? ❑Yes ° 1 have read the ha=Aous 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 requi menta which must be met prior to issuance of a Certificate of Occupancy. Signature of Applicant Date 01, 1All roof coverings to be Class"B" or better mer o a t oriz agcn ate CITY OF CUPERTINO PERMIT RECEIPT OPERATOR: suew 8 ITEMS OF 24 COPY # : 1 Sec: Twp: Rng: Sub: Blk: APN 36603 )67 .00 DATE ISSUED. • • • • . . : 05/BS001/2007 RECEIPT # . . . . . . . . . 167 REFERENCE ID # 07050007 SITE ADDRESS 11845 UPLAND WAY SUBDIVISION • • • . . ' : CUPEFTINO CITY . . . . . . . . . . . . IMPACT AREA . . . . . . OWNER HARLI,N SETHE ADDRESS . . . . . . . . . . : 1184EO UPLAND WAY CITY/STATE/ZIP CUPEPTINO, CA 95014 RECEIVED FROM RECE::PT INTERFACE CONTRACTOR RAND), JIM LIC # 8050 COMPANY . . . . . AAA :?URNACE & AIR CONDITIONING ADDRESS . 1712 STONE AVE CITY/STATE/ZIP S N JOS3,4CA 95125 TELEPHONE . . . . . . . UNIT QUANTITY AMOUNT PD-TO-DT THIS REC- _-NEW-BAL- FEE ID --------- ---------- -- ------------- 0 .00 34 . 86 0 .00 BENERGY PERMIT FEE 1.00 34 .86 0 .00 10 .26 0 .00 BREMAIRHAN NO.UNITS 1.00 10 .26 1.00 14 .31 0 .00 14 .31 0. 00 BREMFURN NO UNIT 0 .00 1 .20 0.00 0 . 90 0 .00 BREMRECEPT NO. OUTLETS 8,4921 ..0000 0.20 0 . 90 0 .00 BSEISMICRE VALUATION 0 .00 38 .37 0 . 00 1.00 38 .37 0 .00 1. 00 EPERMITFEE FLAT RATE 38 .37 0 .00 38 .37 MPERMITFEE FLAT RATE 1.00 38 .37 0 . 00 38 .37 0.00 PPERMITFEE FLAT RATE ---------- --- ------- ---------- 176 .64 0 .00 176 .64 0.00 TOTAL PERMIT METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ---------_------ __ ----------------- CREDIT CARD 529 .32 VISA-JIM RANDO TOTAL RECEIPT 529.32 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -- ------------------ 3 304 ROUGH ELECTRICAL 03 ROUGH MECHANICAL 505 FINAL ELECTRICAL 508 FINAL MECHANICAL CITY OF (..UPERTINO FURNACE/AC r:UPEkTINO PERMIT APPLICATION FORM APN# j Date: U� 0& S / /-a z Building Address: Owner's Name- Phone#: Contractor: Phone: License #: W111'` t-- 1/C10` ' Contact: Phone: Cupertino Businesg License#: D � Building Permit Info: Bldg ❑ Elect :'lumb ❑ Mech Job Description: TG7 Reside tial M Commercial ❑ For Residential Installations: Attic ❑ 1St floor 2nd floor❑ Adhere to min set back requirement vor Commercial Installations: Replacement same weight ❑ Additional weight(siaElctural calcs) Structural Calculations required for new installation New installation Planning Approval Required ❑ Cost of Project: Type of Constru;tion: Occupancy group: Strapped On Platform ❑ Bonded CI Sq.Ft. Floor Area: New Location ❑ Replacement ❑ Qty. if Applicable Fee ID Fee Description Fee Group BENERGY Energy BUILDING BREMFURN Furnace MECHANICAL BREMACOVER A/C Unit> 10,000 cfin MECHANICAL BREMAIRHAN A/C Units<= 10, 000 cfm MECHANICAL BREMRECEPT R.ec tl, Switch & Outlets ELECTRICAL BSEISMICRE Seismic Fee Res BUILDING BSEISMICOM Seismic Commercial BUILIDNG EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMITFEE lv[ech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPLANCHK Plan Check Fee BUILDING BPGAS Cras Piping System Fee PLUMBING BUSLIC E usiness License BUILDING Community Development 10300 Torre Avenue ' Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 -UPEkTINO Building Department JOB ADDRESS: PERMIT # OWNER'S NAME: PHONE # GENERAL CONTRACTOR: FAX# I am not using any subcontractors: Si mature 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 Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile 7 Owner/C ntractor Signature Date