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09070073 CITY OF CUPERTINO p T' BUILDINf.DIVISION PERMIT BUILDING ADDRESS: PERMIT NO. 7504 HOLLANDERRY PL ATLAS—T:ZILLO HvAc n9070073 NER'S NAME: PERMIT ISSUE DATE Y0124— A= NAN 1965 K34- 9 P 2999 PHONE: S A CONTROL NO. (408) 28 -)-8931 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH O Zp LICENSED CONTRACTOR'S DECLARATION U I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description Z with Section 7000)of Division 3 of the Business and o6 ions Code.and my license is Ln in full force and of RMV & R.�PLC FURNACE, ADD A/C UNIT v�Z License CI s Lie.M Date Contractor 6 RCHITBCTS DECLARATION a< I understand my plans shall be used as public records �yU 4 O y Licensed Professional y OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the %O O following mason.(Section 7031.5,Business and Professions Code:Any city or county t$ which requires a permit to convect.alter.improve,demolish,or repair any structure Z yy prior to its issuance,also requites the applicant for such permit to file a signed statement =G that he is licensed pursuant to the provisions of the Contmcwr's License Law(Chapter 9 3q.Ft.Floor Area Valuation Y. I-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 4 6 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 five hundred dollars($500). 36229015 . 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 w e 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 contractor(s)licensed pursuant to the Contractor's License Law. ❑1 am exempt under Sec. B&P C for this mason merDate WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: 0 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 ave and will maintain Worker's Compensation Insurance,as required by Section 37QW the Labor Code,for the performance of the work for which this permit is issued. My Worker mpensation Insurance carrier and Policy number am: Cartier. �� Policy No.: 1-70 C2 i GIif t� CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less) 1 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 Ccrtificaw of Exemption,you should become subject to the Worker's Compensation provisions of the labor Code,you must Oforthwith comply with such provisions or this permit shall be deemed revoked. Z(A CONSTRUCTION LENDING AGENCY [a hN. I hereby affirm that there is a construction lending agency for the performance of (Yi✓ the work for which this permit is issued(Sec.3097,Civ.C.) WGI.Q Lender's Name Z Lender's Address V O 1 certify that I have mad this application and state that the above information is LL►' cormcL 1 agree to comply with all city and county ordinances and state laws relating to Vbuilding convection,and hereby authorize representatives of this city to enter upon the U above-mentioned property for inspection purposes (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs and expenses which may in any way scenic against said City V Z in consequenceof the ranting of this permit. Date r-� APPLICANT ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SOURCE&' L NS,_,.. Re-roofs Signature of Applicant/Conttaetor Date HAZARDOUS MATERIALS DISCLOSURE Type of R.)of Will the applicant or future building occupant atom or handle hazardous material ,s defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety ,dc, Section 25532(a)? All roofs!hall be inspected prior to any roofing material being installed. ❑Yestilding occupant use cyuipmcnl or devices which If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes I have read the materials mquimmcnLs under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building does not cgiveWAhave a tenant,that it is my responsibility to notify the occupant of the mgnirc w_h must be met rior w issuance of a Certificate of cupan Signature A Applicant Date nrammorizcdagent Dave All roof coverings to be Class"J "or better CITY OF CUPERTINO 7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk : Lot : APN 36229016 . 00 DATE ISSUED. . . . . . . : 07/07/2009 RECEIPT #. . . . . . . . . : BSC00008148 REFERENCE ID # . . . : 09C70073 SITE ADDRESS . . . . . : 75C4 HOLLANDERRY PL SUBDIVISION . . . . . . CITY CUI ERTINO IMPACT AREA . . . . . . OWNER YOLNG KENNETH L AND NANCY ADDRESS 75C4 HOLLANDERRY PL CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5040 RECEIVED FROM . . . . : TRILLO RENOVATIONS CONTRACTOR . . . . . . . : TRILLO, STEVE LIC # 4269 COMPANY ATLAS-TRILLO HVAC ADDRESS 19E5 KYLE PARK CT CITY/STATE/ZIP . . . : SAY JOSE, CA 95125 TELEPHONE (4C8) 286-8931 FEE ID UNIT QUANTITY INOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- -- -------- ---------- ---------- ---------- 1BCBSC VALUATION 4, 600 . 00 1 .00 0. 00 1 . 00 0 . 00 1BSEISMICR VALUATION 4, 600. 00 0 .50 0 . 00 0 . 50 0 . 00 1EPERMITFE FLAT RATE 1. 00 42 . 00 0 . 00 42 . 00 0 . 00 1MPERMITFE FLAT RATE 1 . 00 42 . 00 0 .00 42 . 00 0 .00 1MRRAA UNITS 2 . 00 126 . 00 0 . 00 126. 00 0 . 00 1PPERMITFE FLAT RATE 1. 00 42 .00 0. 00 42. 00 0 . 00 1TRAVDOC FLAT RATE 1. 00 42 . 00 0 . 00 42 . 00 0 . 00 -- -------- ---------- ---------- ---------- TOTAL PERMIT 295 .50 0 .00 295.50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 295 .50 4189 --------------- TOTAL RECEIPT 295.50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF C UPERTINO FURNACEAC aCUPEkTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group AIR FURN/AC CONDITIONING 1 BCAIRHAN Commercial A/C Units <= 10k CFM B 1 MCRAA Commercial Mech Repair/alt/add M 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICO Seismic Commercial B 1 PGASCOM 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. C omm/Resid 1BREMAIRHAN Residential A/C units <= IOk CFM B 1 MRRAA Residential Mech Repair/alt/add M r 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residential B 1 EPERMITFEE Electric Permit E 1 MPERMITFEE Mechanical Perm:t M 1 1 PPERMITFEE Plumbing Permit P C1TRAVDOC Travel Documentation B 1BUSLIC Business License B