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09070059foo IOU mU <oUJ. u`j ? ;96 �O Aqye C20 4.9 4'zay Y. 0 BUILDING DIVISION PERMIT 11NG ADDRESS: 'NER'S NAME: ARCHITECl7ENGINEER: LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and cffec . j License Class 11 Date Q Contractor ARCHITECTS DECLA I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the following mason. (Section 7031.5, Business and Professions Cotte: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure 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 (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 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 and Professions Code: The Contractor's License Law does not apply to an owner of 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- ccnse 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 Contractor's License Law. ❑ I am exempt under Sec. B & P C for this reason vner 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. Q 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 Worker's/►C,o.,mpre9nsJattio�n Insurance carrier and Policy number arc: Cartier. M (//✓�C.1_J 14 Policy No.: CERTIFICATE OF EXEMPTION FROM ORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is foronc hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, 1 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 Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 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.) Lender's Name Lender's Address I certify that I have read this application and state that the above information is corrett I agree to comply with all city and county ordinances and state laws relating to building construction. and hereby authorize representatives of this city to enter upon the 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 acme against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMP L WITH ALL NON -POINT SOURCE Sig ature ofXApplicant/LVhLmctor Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material s defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety xie, Section 25532(a)? ❑ Yes , No Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? ❑ Yes 7LI-No 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safety Cade, 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 reouirement,s whidunust.]z met 26aF_ssF1&s9ance of a Certificate of Occupancy. Owner of autho`riz�gcnt — "�� Date 650)321-55 REPLACE FURNACE Sq. Ft. Floor Area 31633118.00 Issued by: Re -roofs Number Job Description Required Inspections Valuation Type Type of Roof All roofs: -,hall be inspected prior to any roofing material being installed. If a roof i:-, installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant Date All roof coverings to be Class' j`` or better PERMIT NO. PERMIT ISSUE DATE S CONTROL NO. BUILDING PERMIT INFO BLDG ELECT PLUMB MECH Job Description Required Inspections Valuation Type Type of Roof All roofs: -,hall be inspected prior to any roofing material being installed. If a roof i:-, installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant Date All roof coverings to be Class' j`` or better 7 ITEMS OF 7 CITY OF CUPERTINO PERMI" RECEIPT Sec: Twp: Rng: Sub: B11:: Lot: APN ........: 31633118.00 DATE ISSUED.......: 07,'07/2009 RECEIPT #.........: BS000008138 REFERENCE ID # ...: 09070059 SITE ADDRESS .....: 10615 PLUM TREE LN SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OPERATOR: SylviaM COPY # : 1 OWNER SAMPSON GURNEY E AND THELMA D ADDRESS 10,615 PLUM TREE LN CITY/STATE/ZIP ...: CUPERTINO CA, 95014-2020 RECEIVED FROM ....: JOHN F DAHL CONTRACTOR .......: GARY CAVAGNARO LIC # 5573 COMPANY DA]3L PLUMBING CO, JOHN F ADDRESS P 0 BOX 450 CITY/STATE/ZIP ...: PA],O ALTO, CA 94301 TELEPHONE ........: (650)321-5500 FEE ID UNIT QUANTITY iUMOUNT PD -TO -DT THIS REC ---------- NEW BAL ---------- ---------- 1BCBSC ------------- VALUATION ---------- 3,000.00 ---------- 1.00 ---------- 0.00 1.00 0.00 1BSEISMICR VALUATION 3,000.00 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 ----------------- CHECK TOTAL RECEIPT : AMOUNT --------------- 295.50 --------------- 295.50 VOICE ID DESCRIPTION -------- ---------------------------- 505 FINAL ELECTRICAL 508 FINAL MECHANICAL REFERENCE NUMBER -------------------- 34612 VOICE ID DESCRIPTION -------- ---------------------------- 507 FINAL PLUMBING CITY OF ..-UPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: PERMIT # OWNER'S NAME: PHONE # GENERAL CONTRACTOR j A L, „� �- L FAX # 13 ~ 3 I am not using any subcontractors: Signature Please check a licable subcontractors and com )lete the following information: Date Owner/ Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing >4— 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 %ITYF CUPEkTINO CITY OFCUPERTINO FURNACE/AC PERMIT APPLICATION FORM OV7105-y APN # 9% (0 33 � � 0 • Date: �. Building Address: �0 y/S- %�v /r c �.r✓ Owner's Name: o Phone #: yob aX-7- S ? Contractor: Phone #: (� o- 3 Z( j D k nJ c.�l-� ` Fax #: Contractor License #: 7o& O, O Cupertino Business License #: '6� S 7 3 Contact: Phone #: 6,�-p 3,2 �GGt/ C,vim•` t�l�— Fax #: l�� l% o`Z 64_0 Building Permit Info: Elect 1] Plumb [� Mech Residential Commercial ❑ Job Description: 1�-c. �-� r w,•- a, c, -tom S 8rn i3 aG o -t - t 11.4 For Residential I stallations: Attic 1St floor? 2nd floor ❑ Adhere to minimum setback re uirement ❑ For Commercial Installations: Replacement same weight ❑ Additional weight (structural calcs) ❑ Structural Calculations required for new installation ❑ New installation Planning Approval Required ❑ Cost of Project: ? DD© W-- Type of Construction (Usage Class): Strapped ❑ On Platform Ki Bondc d ❑ New Location ❑ Replacement Project Size: Ex ress ❑ Standard ❑ Large [] Major ❑ -,- Valuation: � OC90 CvaPn Rnildina• Please comnlete relevant nortion of the Green Building Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Q Revised 01/07/09 CITY OF CUPERTINO FURNACE/AC CUPEkTINO FEE S(:HEDULE Quantity Fee ID Fee Description Fee Permit Type Group FURNACE FURN/AC 1 MCRAA Commercial-R(,-pair/Alteration/Add to M ea heating appl iance,refrigeration unit, cooling unit,ab ,orption unit,or ea heating,cooling,absorption or evaporative cooling system,incl installation of controls regulated by this code. 1 MCREPALT Commercial for the repair of alt/add to M ea heating appl iance,refrigeration unit,cooling unit,VAV boxes, absorption unit or ea heathing, cooling absorption,or evaporative cooling sys, incl install of controls regulated by this code. 1MCSUSHTR Commercial Install/Relocate ea M suspended heater,recessed wall htr, or floor mounted -.nit heater. 1 PGASCOM Commerical for ea gas piping System P 1-4 outlets 1BPGAS For each gas piping system of 5 or P more per outlet. 1MCAPPVNT Commercial for the install/relocate/ or M replacement of ea appliance vent installed & not incl in an appliance permit. 1BCBSC Cal Bldg Stancards Commission Fee B ALL PERMIT TYPES 1BSEISMICO Commercial Scismic B 1MRRAA Residential Re-)air/Alteration/Add to M ea heating app] iance,refrigeration unit, cooling unit,absorption unit,or ea heating,coolin;,absorption or evaporative co,)ling system,incl installation of controls regulated by this code. 1MRSUSHTR Residential Install/Relocate ea M suspended hea::er,recessed wall htr, or floor mounted unit heater. OCIF CUPEkTINO CITY OF CUPERTINO FURNACE/AC FEE SCHEDULE Quantity Fee ID Fee Descripti 3n Fee Group Permit Type AIR CONDITIONING FURN/AC 1BCAIRHAN Commercial A/C Units <= IOk CFM B 1 MCRAA Commercial M -1ch Repair/alt/add M 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICO Seismic Commercial B 1PGASCOM Commerical f6- ea gas piping System to 1-4 outlet. P Residential for ea gas piping system of 1-4 Outlets P 1BPGAS For each gas pipmg system of 5 or more per outlet. Comm/Resid P 1 BREMAIRHAN Residential A/(; units <= l Ok CFM B 1MRRAA Residential Mech Repair/alt/add M j 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residential B t I 1 EPERMITFEE Electric Permit E 1 MPERMITFEE Mechanical Pe mit M r 1PPERMITFEE Plumbing Pemdt P 1 TRAVDOC Travel Documontation B 1 BUSLIC Business License B