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11080042CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22670 LIBERTY OAK LN CONTRACTOR: BAY MOUNTAIN AIR PERMIT NO: 11080042 OWNER'S NAME: WESTRIDGE COUNTRY CLUB HOMES ASSN 88 DILLON AVE DATE ISSUED: 08/04/2011 (-7" 1ER'S PHONE: 4085591977 CAMPBELL, CA 95008 PHONE NO: (408)378-6375 CJ LICENSED CONTRACTOR'S DECLARATIONr BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class C -?-.i Lic. # 7 x 3 5 7 r r � MECH RESIDENTIAL COMMERCIAL Contractor OVj �-: �jo_Ar Date S/y/11 I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: ADD AIR CONDITIONING TO EXISTING FORCED AIR (commencing with Section 7000) of Division 3 of the Business & Professions CENTRAL HEATING SYSTEM 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. I have and will maintain Worker's Compensation Insurance, as provided for by Sq. Ft Floor Area: Valuation: $4627 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APN Number: 34232996.00 Occupancy Type: APPLICANT CERTIFICATION 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 upon the above mentioned property for inspection purposes. (We) agree to save PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally, the applicant understands and will comply 18 DAY ROM LAST CALLED INSPECTION. with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Issued by: (�•�7 Date: Signatur JV OWNER -BUILDER DECLARATION RE -ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed. If a roof is the following two reasons: installed without first obtaining an inspection, I agree to remove all new materials for I, as owner of the property, or my employees with wages as their sole compensation, inspection. will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) Signature of Applicant: Date: I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's HAZARDOUS MATERIALS DISCLOSURE Compensation, as provided for by Section 3700 of the Labor Code, for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain I have and will maintain Worker's Compensation Insurance, as provided for by compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Section 3700 of the Labor Code, for the performance of the work for which this Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued, I shall maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health & Safety Code, Sections 25505, 25533, and 25534. Compensation laws of California. If, after making this certificate of exemption, I �thorize become subject to the Worker's Compensation provisions of the Labor Code, I must Own Ylvbf forthwith comply with such provisions or this permit shall be deemed revoked. Date: CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct. I agree to comply with all city and county ordinances and state laws relating for which this permit is issued (Sec. 3097, Civ C.) to building construction, and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, Lender's Address r and expenses which may accrue against said City in consequence of the ng of this permit. Additionally, the applicant understands and will comply ARCHITECT'S DECLARATION ww. all non -point source regulations per the Cupertino Municipal Code, Section 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 6 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 34232996.00 DATE ISSUED.......: 08/04/2011 RECEIPT #.........: BS000014313 REFERENCE ID # ...: 11080042 SITE ADDRESS .....: 22670 LIBERTY OAK LN SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ...... OWNER ............: WESTRIDGE COUNTRY CLUB HOMES A ADDRESS ..........: 1935 DRY CREEK RD STE 203 CITY/STATE/ZIP ...: CAMPBELL, CA 95008-3631 RECEIVED FROM ....: BAY MOUNTAIN AIR IN CONTRACTOR .......: TODD STONE LIC # 24700 COMPANY ..........: BAY MOUNTAIN AIR ADDRESS ..........: 88 DILLON AVE CITY/STATE/ZIP ...: CAMPBELL, CA 95008 TELEPHONE ........: (408)378-6375 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC ---------- NEW BAL ---------- -ADMIN ------------- HOURS ---------- 1.00 ---------- 41.00 ---------- 0.00 ---------- 41.00 0.00 1BCBSC VALUATION 4,627.00 1.00 0.00 1.00 0.00 1BREMAIRHA NO.UNITS 1.00 65.00 0.00 65.00 0.00 1BSEISMICR VALUATION 4,627.00 0.50 0.00 0.50 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 ---------- 195.50 ---------- 0.00 ---------- 195.50 0.00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- 505 FINAL ELECTRICAL -------- 507 ---------------------------- FINAL PLUMBING 508 FINAL MECHANICAL I�A&-7 D Ubtl�� 41-L& <<4(-)0q,-) ENE PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX ((408) 7.7 3- 3 • building(d)cupertino.org misc CUPERTINO C C -i. PLUMBING MECHANICAL ❑ELECTRICAL [:]MISCELLANEOUS PROJECT ADDRESS APN OWNER NAME I _ \ C b j �` PHON 'y n `' ^ I r E-MAIL STREET ADDRESS CITY. STATE, ZIP TFAX CONTACT NAME Moor- /1,/ PHON(qot' -/q7 E %U1rib iCI (0~0441M4A4 STREET ADDRESS L PorX CITY, C�A�M ZIP ',� 5 0 V, F 4 o Y C T I �D ❑ OWNER ❑ OWNER -BUILDER I�j OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME 1� 9,,�v+ t Ac, LICENSE NUMBERr 703 576 LICENSE TYPE C- Za BUS. LIC COMPANY NAME J ^ r" E-MAIL�e�� // 10 ✓ FA _7 0 3 7 - 6 3 STREET ADDRESS 91 A 1 6'A1 AVL CI caSTATE, ZIP r id 5. D D �y d PHO ARCHITECT/ENGINEER NAME LICENSE NUMBE BUS. LIC COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD.r DUPLEX ❑ MULTI -FAMILY BUILDING: ❑ COMMERCIAL PROJECT IN WILDLAND ❑ YES URBAN INTERFACE AREA ^� NO PROJECT IN ❑ YES FLOOD ZONE '� NO IS THE BLDG AN ❑ YES EICHLER HOME? NO DESCRIPTION OF WORK 1 ex;U Ce�n+�-wAt TOTAL VALUATIONC ! G ') RECEIVED BY: By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information 1 have pro d is correct. I have read the Description of Work and verify it is accurate. 1 agree to comply with all applicable local ordinances and state laws relating to g construction. I authorize representatives of Cupertino to enter the above -i �ntified property for inspection purposes. Signature of Applicant/Agent: s Date: SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY ❑ OVER-THE-COUNTER pWp F ❑ EXPRESS U W S U t a ❑ STANDARD ❑ LARGE ❑ MAJOR MEPMiscApp_201 Ldoc revised 06/21/11 ,4 , co')