09010115 -77
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
20880 TULA CT AAA FURNACE & AIR 09010115
OWNER'S NAME: CONDITIONING PERMIT ISSUE DATE
O S A CONTROL NO.
(408) 293-4717
ARCHTIECTIENGINEER: BUILDING PERMIT INFO
BLDG EO PLUMB ME�CH
o O p LICENSED CONTRACTOR'S DECLARATION
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
3 5 with Section 7000)of Divi n 3 of the Business and Professions Code,and my license is
o y in full force and feel. fob f 7 r RPLC FURNACE 10 0, 0 0 0 BTU& AD A/C 4 TON
D vl z License Class Lic.R
Date Contractor
ARCHITECTS DECLARATION
< I understand my plans shall be used as public records
5qU
U.y Licensed Professional
n y OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
4 m� which requires a permit to construct.alter,improve,demolish,or repair any structure
o Z y 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
yf— (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 7 2 0 0
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 rive hundred dollars(s500). 35913057 . 00
❑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 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.).
❑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 Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a cont actors)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec B do 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-
-don,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
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workke/err�'s'''ICom pensation Insu carrier and Polity number am: r
Carrier..<it, �✓f 4 Policy No.:�/ S Co�J_GT
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('ibis section need not be compacted 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 az 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
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
z 0-4 CONSTRUCTION LENDING AGENCY
HCn 1 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�.A Lendees Name
z Lcodee Address
U 0 I certify that 1 have read this application and state that the above information is
LL►'c correct.l agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authon' presentatives of this city to enter upon the
W shove-mentioned propcny for inspectia s
G7~ (We)agree to save,inrd
harmless the City of Cupertino against
Hto liabilities,judgments,costs anmay in any way accrue against said City l 1
U Z in consequence of the grantin Dcte
A 1CANT LINDERSTACOMPLY WITH ALL NON-POINT Issued by:
OUR EGULATIONS.
—2 —0 Re-roofs
erre ol'Applica t Contractor Dare Type of Roof
HAZARDOUS MA ALS DISCLOSURE b1
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 beln`g i sed.
❑Yes
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
hazardous air contaminants az defined by the Bay Arca Air Quality Management all new materials for inspection.
rict?
❑Yes 4
1 have read the hazardous m uimmcros under Chapter 6.95 of the Califor-
ni afcty COdc,Sectio 533 and 25534.1 understand that if the building
ocs not cu ndy have a tena n is my responsibility to notify the occupant of the
rcqu rcmc which must be m rior to issuance of a Certificate of Occupancy. Signature of Applicant Date
e-
mer raw,,,/z,authorized agent Z Date _ All roof coverings to be Class';j.`'or better
CITY OF CUPERTINO
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35913057 . 00
DATE ISSUED. . . . . . . : 01/27/2009
RECEIPT #. . . . . . . . . : BS000007046
REFERENCE ID # . . . : 09010115
SITE ADDRESS . . . . . : 20880 TULA CT
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : TRYFOROS JAMES M AND OLGA
ADDRESS . . . . . . . . . . .
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2933
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 7, 200 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 7, 200 . 00 0 . 80 0 . 00 0 . 80 0 . 00
lEPERMITFE 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 2 . 00 122 . 38 0 . 00 122 . 38 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 287 . 34 0 . 00 287 . 34 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 287 . 34 VISA
---------------
TOTAL RECEIPT 287 .34
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
CITY OF CUPERTINO n ��
FURNACE/AC
CUPEkTiNO PERMIT APPLICATION FORM
APN# q C3 Date:
Building Address:
Owners Name: Phone #:
bee- C ��/6(-- *,e- - z_
Contractor: Phone #: m -,,,7 _ )1>
Fax #:
Contractor License#: j Cupertino Business License#:
OFZI
Contact: Phone #: ,yiG,�,,�
y T/I Gtr 'Zs 6,e
Fax #:
Building Permit Info:
Elect�+ Plumb [ V Mech [ I
Residential Commercial
Job Description:
For Resid ntial Installations:
Attic ❑ 1St 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):
Strapped On Platform El Bonded New Location Replacement
Project Size: Ex ress [g---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
141F FURNACE/AC
CUPEkTINO FEE SCHEDULE
Group
FURNACE FURN/AC
1 PGASRES Residential for ea gas piping system of P
1-4 Outlets
1 BPGAS For each gas piping system of S or P
more per outlet.
1BSEISMICR Residential Seismic B
1MECPLNCK Mechanical Plan Check M
1MFR=<100 Furnace Syst<=100k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance up to and
include 100,000 Btu/h
1MFRN>100 Furnace Syst> I 00 BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance over
100,000 Btu/h
A 1 EPERMITFEE Electric Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
1 1PPERMITFEE Plumbing Permit P
1TRAVDOC Travel Documentation B
1 BUSLIC Business License B
Quantity Fee ID Fee Descri tion Fee Permit Type
INPUT Resources Energy A!
n oor Afr ua ity and I ashes
1.Use Low/No-VOC Paint 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes. 0
3.Use Low/No VOC Adhesives 3 IAQ/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7..S".allxposed�Plartcleboard:orMDF 41AQ/Health pts y=yes 0
8.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 0
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0
2.Use:Rapidly Renewable.Flooring Materials 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
6. Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
1 1 1
Total Points Available: 1 1401 130 57
Total Points Project Received: 0 oi 0
� l
G:data/progs/greenbuildingguidelines/remodelers/greenpointsfinal2.12.D4protected.xis
Community Development
10300 Torre Avenue
°:; Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
r:UPEkTINO
Building Department
JOB ADDRESS: PERMIT
OWNER'S NAME: 'Zee- PHONE # " C
GENERAL CONTRACTOR: ly5 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
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date