11090105 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10201 FIRWOOD DR CONTRACTOR:JIM'S AIR PERMIT NO: 11090105
CONDITIONING
"WNER'S NAME: SWANSON DONALD A ET AL 917 QUERCUS CT DATE ISSUED:09/16/2011
.NNER'S PHONE: SUNNYVALE,CA 94086 PHONE NO:(408)655-0491
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIAL
License Class C^ar) _ Lie.# Yl(24 1 f) REPLACE FURNACE&A/C
Contractor VA 5 A I r(b y4 i+&k-.Date 5-14—((
I hereby affirm that I am licensed under the 90visions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$6000
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the workywhic his APN Number:34235038.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY ROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, l
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply Issued by: G Date:
with all non-po sour a regulations per the Cupertino Municipal Code,Section
9.18.
/ RE-ROOFS:
Signature Date All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,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&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Senp 56 25533 and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agent: Date:
1 certify 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 Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information is
correct.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
-n the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
nnify and keep harmless the City of Cupertino against liabilities,judgments,
,is,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 34235038 . 00
DATE ISSUED. . . . . . . : 09/16/2011
RECEIPT #. . . . . . . . . : BS000014773
REFERENCE ID # . . - : 11090105
SITE ADDRESS . . . . . : 10201 FIRWOOD DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : SWANSON DONALD A ET AL
ADDRESS . . . . . . . . . . : 417 LINAKA ST
CITY/STATE/ZIP . . . : SEATTLE WA, 98115
RECEIVED FROM . . . . : JIM AIR CONDITION.
CONTRACTOR . . . . . . . : JIM TURNER LIC # 25053
COMPANY . . . . . . . . . . : JIM' S AIR CONDITIONING
ADDRESS . . . . . . . . . . : 917 QUERCUS CT
CITY/STATE/ZIP . . . : SUNNYVALE, CA 94086
TELEPHONE . . . . . . . . : (408) 655-0491
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 6, 000 . 00 1. 00 0 . 00 1 . 00 0 . 00
1BREMAIRHA NO.UNITS 1 . 00 65 . 00 0 . 00 65 . 00 0 . 00
1BSEISMICR VALUATION 6, 000 . 00 0 . 60 0 . 00 0 . 60 0 . 00
1BUSLIC FLAT RATE 1 . 00 115 . 00 0 . 00 115 . 00 0 . 00
1MFR=<100 UNITS 1 . 00 130. 00 0 . 00 130 . 00 0 . 00
1MPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00
1TRAVDOC FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 399. 60 0 . 00 399 .60 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 399. 60 12760
---------------
TOTAL RECEIPT 399. 60
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CtJPERTINO (408)777-3228• FAX(408)777-3333• building(a�cuperbno.org MISC
❑PLUMBINGMECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS APN#
OWNER NAME J W 14w c O l PHOS
STREET ADDRESS J KJ CITY, STATE,ZIP FAX
CONTACT NAME�' w,^�' V✓, A'e PHOIP r SQL^Q EMAIL
STREET ADDRESS F/7 �v cv Y/,, _ �L CITY,STATE, ZIP_K u�� FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENTCONTRACTOR ❑CONTRACfORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME /l 1 f 49�K�/1. 1� l :�46 6 vo
LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME E- FAX
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STREET ADDRESS , ^C� clrY.srwrE,ZIP50
Al u v v Af� PHONE �b D 4}
ARCHITECT/ENGINEER NAME K LICENSE NUMBER ! BUS.LIC#
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ElYES PROJECT IN [3YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION: /�)/? ( "L' RECEIVED BY:
By my signature below,I prtify to each of the fo owing: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provi is correct.I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to bAldi cons a representatives of Cupertino to enter the above-identified properly for inspection pufposes.
Signature of Applicant/Agent: Date:
77--
S4ALEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
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MEPMiscApp_2011.doc revised 06/21/11