11010058 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10770 PENINSULAR AVE CONTRACTOR:AAA FURNACE&AIR PERMIT NO:11010058
CONDITIONING
OWNER'S NAME: YOUNG JOSEPH A JR AND SANDRA R 1712 STONE AVE DATE ISSUED:01/10/2011
'iER'S PHONE: 4158066303 SAN JOSE,CA 95125 PHONE NO:(408)2934717
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT r PLUMB
License Class Lic.# -7(a -7 ( r r (�
MECH RESIDENTIAL COMMERCIAL
Contractor Tin
I'N� Date ^�U 10
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE EXISTING FURNACE&REPLACE EXISTING IN
(commencing with Section 7000)of Division 3 of the Business&Professions SAME
Code and that my license is in full force and effect. LOCATION
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
Section 3700 of the Labor Code,for the performance of the work for 11ip)I this Sq.Ft Floor Area: Valuation:$5300
permit is issued. (�)J/
APPLICANT CERTIFICATION APN Number:32603051.00 Occupancy Type:
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 ' h accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this prnit. ionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-P0,01 so gulations per the Cupertino Municipal Code,Section
9.18.
_
Signator /0—//�G—! Issued by: Date:
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
constrict 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: HAZARDOUS MATERIALS DISCLOSURE
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 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. 1 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.
kddally,should I equipment or devices which emit hazardous air
permit is issued. nants e y 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 n hod
ce th 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 afe o ,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
ar rized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. ate'
CSTRUCTION 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
in-temnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
and expenses which may accrue against said City in consequence of the
_.ring of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Signature Date Licensed Professional
CITY OF CUPERTINO
5 ITEMS OF 25 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 32603051 . 00
DATE ISSUED. . . . . . . : 01/10/2011
RECEIPT #. . . . . . . . . : BS000012441
REFERENCE ID # . . . : 11010058
SITE ADDRESS . . . . . : 10770 PENINSULAR AVE
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : YOUNG JOSEPH A JR AND SANDRA R
ADDRESS . . . . . . . . . . : 10770 PENINSULAR AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-0100
RECEIVED FROM . . . . : RANDO AAA HVAC, INIC
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 5, 300. 00 1.00 0.00 1. 00 0 . 00
1BSEISMICR VALUATION 5, 300. 00 0 .53 0.00 0 . 53 0 .00
1MFR=<100 UNITS 1. 00 126 . 00 0 . 00 126.00 0 .00
1MPERMITFE 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 211 .53 0 .00 211.53 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 956 .53 #37838
---------------
TOTAL RECEIPT 956 .53
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
------ ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN # t;� Date: I _ -7 --4
Building Address:
10-7-70 a nntt,t a r 14✓L
Owner's Name: Phone#:
OC' aun C,4 qWW- y r 5 - 8,66 - (o 30
Contractor: Phone #:410 k_029 3 -q 7/ 7
�NCcG-� l 9✓A C Fax #: qOk -AC13 -- (D 7-7
Contractor License#: ..7 O8$- ( Cupertino Business License#:
Contact: '�C1h C+`tGI�N C C`Z Ger (Gc�Z �r Phone #: Lt 66--d 93 L�7I 7
Fax #: ag 3 - (0 7-7 f
Building Permit Inf
Elect Plumb Mech ❑�
Residential Commercial El
Job Description: 1Ze r►'xOJ Q r �tiG S�'�►'�q 44 r!J On!
e
��iS��nS N s4 w•e I 4-
For Residential Installations:
Attic ❑ 1 S` 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: ��-- 3b0 �,v Type of Construe `J (Usage Class):
Strapped On Platform Bonded 0 New Location Replacement
Project Size: Express ❑ Standard ❑ Lar e ❑ Major ❑ _
Valuation: 9i 5.300.vv
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 01/07/09