06100139 CITY OF CUPERTINO
CUILDINGd)IVISION PERMIT 'RAG' OR IMTI��Y�
BUILDING ADDRESS: AAA FURNACE & AIR GONDITI T 11V6• 06100139
19373 GREENWOOD
OWNER'S NAME:
PERMIT ISSUE DATE
SARA FRAZIER 1712 STONE AVE in /1R /?nnr,
JNE: SANITARY NO. CONTROL NO.
408293-4717
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION
U - 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is
y in full force andeff t Yj REPLACE FURNACE 6 0 0.0 0 BTU
z License Class a Lic.0 I a
t-aDate — Contractor
—3 A HITECTS DEC O
m U I understand my plans shall be used as public records
ul
O in Licensed Professional
i 0, OWNER-BUILDER DECLARATION
3 a I hereby affirm that I am exempt from the Contractors License Law for the
00 following reason.(Section 7031.5,Business and Professions Cale:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
Z r 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 License Law(Chapter 9 Sq.Ft. Floor Area Valuation
I—$ (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 fir, 00 Occupancy Type
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 Required Iections
and Professions Cade:The Contractor's Licennsse Law dots not apply to an owner of q 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 Cade:)The Contractor's U.
cense Caw 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.
❑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:
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 Cade,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.45kd 4.9,�Polity No:h�3
lCTI A E O•EXEMPTION 1°RO 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 Califomi&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.
z OCONSTRUCTION LENDING AGENCY
tz I hereby affirm that there is a construction lending agency for the performance of
p� the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
az Lender's Address
U 0 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 state laws relating to
O U building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
W /?
(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
U Z in consequence of the granting of this permit. Date
�+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: C/
SOURCE REGUL ONS.
Re-roofs
SigfiatUre of phcanUContrac Dic
HAZARDOUS 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
Cede,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑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
-mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
1 have read the haz ous 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
requirements which must be met prier to issuance of a certificate of Occupancy. Signature of Applicant Date
er o u c'red agcn
— Date k.r:- _" All roof coverings to be Class"B"or better
CITY OF CUPERTINO
em 2 of 2 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 37543007 . 00
DATE ISSUED. . . . . . . : 10/18/2006
RECEIPT # . . . . . . . . . : 36486
REFERENCE ID # . . . : 06100139
SITE ADDRESS . . . . . : 19373 GREENWOOD DR
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : SARA FRAZIER
ADDRESS . . . . . . . . .
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : JIM RANDO
CONTRACTOR . . . . . . . : RANDO, JIM LIC # 8050
COMPANY . . . . . . . . . . : AAA FURNACE & AIR CONDITIONING
ADDRESS . . . . . . . . . . : 1712 STONE AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408) 293-4717
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
- - -- - - - --- -- - ----- ------ - --------- ------- --- -- - ------- ----- ----- ----------
BREMFURN NO UNIT 1 . 00 14 . 31 0 . 00 14 . 31 0 . 00
BENERGY PERMIT FEE 1 . 00 34 . 86 0 . 00 34 . 86 0 . 00
BSEISMICRE VALUATION 1, 975 . 00 0 . 50 0 . 00 0 . 50 0 . 00
PPERMITFEE FLAT RATE 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 0 . 00
--- ---- - -- ---- ------ ----- --- -- ----------
TOTAL PERMIT 164 . 78 0 . 00 164 . 78 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
- - - - - -- -- - - ----- - - - ----- ----- ---- ---- ----------
OTHER 329 . 56 VISA
TOTAL RECEIPT 329 . 56
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL
CITY OF CUPERTINO Qv 1 QOI-39
FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN# .1� � Date:
Building Address:
Owner's Name: Phone#:
�2 iA Z o? � 7
Contractor: Phone: License #:�
t'& C�
Contact: Phone: Cupertino Business License#:
,6',q �S?
Building Permit Info:
Bldg ❑ Elect Plumb 'B— Mech 0--/
Job Description:
O
Resid tial 0 Commercial ❑
For Residential Installations:
Attic ❑ 1St floor Cl' 2nd floor❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: Occupancy group:
�-
Strapped ❑ On Platform B' Bonded C� Sq.Ft. Floor Area:
New Location ❑ Re lacement ff
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 cfin MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BPGAS Gas Piping System Fee PLUMBING
BUSLIC Business License BUILDING