09010043 CITY OF CUPERTINO
BUILDING DIVISION PERNIIT1T4�C)
BUILDING ADDRESS: PERMIT NO.
21793 OLIVE AVE AAA F
OWNER'S NAME: CONDITIONING PERMIT ISSUE DATE
SA CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
REMOVE AND ADD 2 FURNACES I
a p C LICENSED CONTRACTOR'S DECLARATION LAUNDRY ROOM & DUCTS Job Description
U) I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 70(X0)of Division 3 of the Business and Professions Code,and my license is
CA in full force and a qc-
Z License Class I n'J Lic.k
E„ Date /.•t9 s'�—ContractorAeGg
ARCHITECT'S DECLA r
Ak
C6
U I understand my plans shall be used as public recordsf
Gin Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License law for the
O O following reason.(Section 7031.5,Business and Professions Code:Any city or county
$Pi which requires a permit to construct,alter,improve,demolish•or repair any structure
y Z y prior to its issuance,also requires the applicant for such permit to file a signed statement
E s C that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
X F- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y .. 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($500).
0 I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractors License Law does not apply to an owner of q p
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion,the owner-
builder will.have the burden of proving that he did not build or improve for purpose of
sale.).
0 I.as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors li-
cense Law docs not apply to an owner of property who builds or improves thereon,and•
who contracts for such projects with a conuactor(s)licensed pursuant to the Contractors
License Law.
0 1 am exempt under Sec. B$P C for this reason
OwnerDate
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 Code,for the performance of the
work for which this permit is issued.
I have and will maintain Workers Compensation Insurance,as required by Section
of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier.,�/70& /y.4 c-)I/ Policy No.:
CERTIFICATE OF EXEMPI7ON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or Ices.)
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 at 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
,J 0 forthwith comply with such provisions or this permit shall be deemed revoked.
Z"~ CONSTRUCTION LENDING AGENCY
F.t Cn I hereby affirm that there is a construction lending agency for the performance of
t.7~5 the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lenders Name
]z Lcndees Address
(� I certify that I have read this application and sate that the above information is
correct.I 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
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
►F-u C4 liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. .7
�+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOfj4CE REGULATIONS.
w- Re-roofs �y _
S7gnstureof Applicant/Contractor I Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino �N-
cip dc,Chapter 9.12.and the Health and Safety
Code,Scction 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
At hazardous air contaminants as def d by the Bay Arca Air Quality Management all new materials for inspection.
Jistrict?
0 Yes
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health k Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
rcgmi menu which must be met prior to issuance of a Certificate of Occupancy. Signature of Applicant Date
—u , e d � &-e of All roof coverings to be Class'n"or better
Owner or authorized agent Date
CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN# 5-7
/ p D ZQ. � �_ Date:
Building Address: /
q�
Owner's Name: Phone#:
Contract r. Phone #:4/,A -
P�_ �1.�- e, c Fax #:
Contractor License #: Cupertino Business License#:
�'t f d 0 �I
Contact: Phone#:
Fax #:
Buildin Permit Info:
Elect [ Plumb Mech
Residential Commercial
Job Description: J JG w A Q o 06 m0 AI I�(,J s/ { 1
ee
` t
For Re i ential Installations:
Attic ❑ 1 St floor ,� 2nd floor ❑
Adhere to minimum setback 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 (Usage Class):
01
Strapped On Platform Bonded New Location Replacement
Project Size: Express Standard ❑ Large ❑ Major ❑
Valuation:
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index.
Revised 6/16/08
CITY OF CUPERTINO
FURNACE/AC
CUPEkTiNO FEE SCHEDULE
-Group
AIR FURN/AC
CONDITIONING
1BCAIRHAN Commercial A/C Units <= IOk CFM B
1MCRAA Commercial Mech Repair/alt/add M
1BSEISMICO Seismic Commercial B
1PGASCOM Commerical for ea gas piping System P
1-4 outlets
1 PGASRES Residential for ea gas piping system P
of 1-4 Outlets
1BPGAS For each gas piping system of 5 or P
more per outlet. Comm/Resid
1BREMAERHAN Residential A/C units <= l0k CFM B
1MRRAA Residential Mech Repair/alt/add M
�i 1BSEISMICR Seismic Residential B
IWO-AN
1 EPERMITFEE Electric Permit E
1MPERMITFEE Mechanical Permit M
1 PPERMITFEE Plumbing Permit P
1TRAVDOC Travel Documentation B
1BUSLIC Business License B
Green,Building Plan Check
Index of Green Building Points/Categories
A- Category Example of an Index or Table of Green Plan Sheet or Page Points
Building Points Categories that must be
shown and referenced on the Project
Plans See below
B. Site 9. Install H.E. Irrigation, (details/spec)• L-1 2 points
11. Permeable Paving, Note L-1 2 points
-C. Foundation 1. Use 15 % Flyash Concrete, (note) S-1 5 points
D. Structural 3. Uses Wood I-Joist, (See Spec.) S-2 2 points
5. Use Truss with heels, (detail) S=2 2 points
6. B. OSB Sheathing, detail S-2 2 points
E. Ext. Finish 1. Composite Decking, (Note/Spec.) A-3 2 points
4. B. Fiber Cement Siding, (Note/Spec. A-4 2 Points
F. Plumbing 1. Insulate all H.W. pipes, (Note/Spec.) P-1 2 points
5. Tankless W.H., (Note/Spec.) A-2 2 points
11. A 2500 Gal. Tank, (Note/Spec L-1 10 points
G. Electrical 4. E. Ceiling Fans, (Note/Spec.) A-3 4 points
H. Appliances 1. Energy Star Dishwasher, (Note/Spec.) A-3 1 point
3. Energy Star Refrigerator, (Note/Spec. A-3 1 point
—
P. Other 1. List Green Features on Plans A-1 1 point
TOTAL POINTS 40 points
Plan Review Process Work Book Page-12-Revised 3/25/08
CITY OF CUPERTINO
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . . 35718029 . 93
DATE ISSUED. . . . . . . : 01/09/2009
RECEIPT #. . . . . . . . . . BS000006945
REFERENCE ID # . . . : 09010043
SITE ADDRESS . . . . . : 21793 OLIVE AVE
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . . ROGER SY
ADDRESS . . . . . . . . . . . 21793 OLIVE AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
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
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 13, 743 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 13 , 743 . 00 1 .40 0 . 00 1 .40 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1MPERMITFE FLAT RATE 1. 00 40 . 79 0 . 00 40 . 79 0 . 00
1MRRAA UNITS 4 . 00 244 .76 0 . 00 244 .76 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 .79 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 410 . 32 0 . 00 410 . 32 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 410.32 VISA
---------------
TOTAL RECEIPT 410 .32
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
Community Development
10300 Torre Avenue
Cupertino CA 95014
A4
Telephone(408)777-3228
S
av OF Fax(408)777-3333
'.-,UPEkT1N0
Building Department
JOB ADDRESS: PERMIT #
OWNER'S NAME: PHONE #i.'
GENERAL CONTRA OR: #
I am not using any subcontractors:
Signature Date
Please check apphcable 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
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date