06100134 CITY OF CUPERTINO
BUIL ON DIVISION PERMIT � RAT�1R I� } MTI4IN*
BUILDING ADDRESS: A & H HEATING PERMIT NO. 06100134
11731 SOUTTISTIORE CT
OWNER'S NAME:
PERMIT 155UE DATE
LIOU RESIDENCE 770 CH SINTIT ST in /ig/2oo(;
NE: SANITARY NO. CONTROL NO.
(408) 279-0722
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O
Z
LICENSED CONTRACTOR'S DECLARATION
W I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
z o with Section 7000)of Division 3 of the Business and Professions Code,and my license is
! H in full force and effect. '^ op Y(� Z ADD A/C
>�? License CI �-�/ Lic.N01
t- Date — Contractor
a ARCHITECTS DECLARATION
wU I understand my plans shall be used as public records
,a
F„ Licensed Professional
W', OWNER-BUILDER DECLARATION
3< I hereby affirm that 1 am exempt from the Contractor's License Law for the
.00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
%P 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
_< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
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 lr 0 0 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 Inspections
and Professions Code:The Contractor's License 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 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 contractors)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:
❑1 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 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 I urance carrier and Policy nu :r —97
Carrier.. �p_ AW-5 Polity No.: I O `
CERTIFICATE OF EXEMPTION FRO W ERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certifv 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 Cade,you must
0 forthwith comply with such provisions or this permit shall be deemed revoked.
z" CONSTRUCTION LENDING AGENCY
E"rte" 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
Lender's Address
U Q I certify that I have read this application and state that the above information is
LL+" correct.I agree to comply with all city and county ordinances and state laws relating to
0U building construction,and hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes.
a
H f Crtin
(We)agree to save,indemnify and keep harmless the City of 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 /
�-" APPLICA UNDERSTANDS AND W LL COMPLY WITH ALL NON-POINT Issued by:
SOURCE ULATIONS.
4271Re-roofs
Signature o pp scant/ ontractor or Date
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
Cole,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes Nu
I have read the hazardous materials requirements under Chaptcr 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand thatif the building
docs not currently have a tenant that it is my nsibility to notify the occupant of the
requiremen which must be met prior to iss c a Cc frcatc of Oc an Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner or authorized agent Date
CITY OF CUPERTINO
oem 1 of 2 PERMIT RECEIPT OPERATOR: amyw
COPY ## 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 36653008 . 00
DATE ISSUED. . . . . . . : 10/18/2006
RECEIPT ## . . . . . . . . . : 36483
REFERENCE ID ## . . . : 06100134
SITE ADDRESS . . . . . : 11731 SOUTHSHORE CT
SUBDIVISION . . . . . . .
CITY. . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : LIOU RESIDENCE
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : DALE PHELPS
CONTRACTOR . . . . . . . : PHELPS, DALE LIC # 12079
COMPANY . . . . . . . . . . : A & H HEATING
ADDRESS . . . . . . . . . . : 770 CHESTNUT ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95110
TELEPHONE (408) 279-0722
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
- - - - --- - - - - ---- -------- --- ----- -- ---------- ---------- ------ ---- ----------
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
BENERGY PERMIT FEE 1 . 00 34 . 86 0 . 00 34 . 86 0 . 00
BSEISMICRE VALUATION 4 , 450 . 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 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
FURNACE/AC
XPEi�TINO PERMIT APPLICATION FORM
APN# Date:
36� 53 008
Building Address: r 73lCr
Phone It
Owner's Name: �S3
: _ Phone: License
ContractorA #�
r, N� 4 a79 o�a �. 7� ---
Contact: Phone: Cupertino Business License 4.
hath �H�� 02o ��
Building Permit Info:
Bldg ❑ Elect . Plumb Mech
Job Description:
Residential Commercial ❑
For Residential Installations: .
Attic ❑ l" floor ❑ 2"d floor El ;K
Adhere to min set back requirement Nz
,For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation P Approval Required ❑ Occupancy group-
Cost
of Projec : Type of Construction: P y '
. Strapped ❑ On Platform
Bonded Ei Sq.Ft. Floor Area:
New Location Re lacement ❑
Qty. if Fee Descri tion Fee Grog
Applicable Fee ID BUILDING
BENERGY Energy
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfin MECHANICAL �
B ,gpIN A1C Units<= 10, 000 cfm MECHANICAL
Sw
BRE MRECEPT Rec tl, itch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbin Permit Issue PLUMBING
BPERMFEE Bld Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING _