10110117 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10557 RANDY LN CONTRACTOR:ATLAS-TRILLO HVAC PERMIT NO: 10 110 117
OWNER'S NAME: PAULSEN GEOFFREY L AND JANINE 1965 KYLE PARK CT DATE ISSUED: 11/19/2010
'NER'S PHONE: 4084807509 SAN JOSE,CA 95125 PHONE NO:(408)286-8931
LICENSED CON ' OR'S DECLARATION I r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class ic.
MECH RESIDENTIAL COMMERCIAL
Contractor a
I hereby affirm that I am lic sed under the isions of Chapter 9 JOB DESCRIPTION:REMOVE AND REPLACE FURNACE IN SAME LOCATION
(commencing with Section 70 0)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:$2500
1 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 which this
permit is issued. APN Number:31602053.00 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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless t of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which a m ainst said City in consequence of the
granting of this peA it. A ition y, applicant understands and will comply
with all on-point sour ula ons he Cupertino Municipal Code,Section Issued by; Date:
9.18. J '
Signature Date l l q l
RE-ROOFS:
Li OWNER BUILDER DECLARATION 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
I hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this co taminanIs as fined b ay rea Air Quality Management District I will
permit is issued. m ntain comp lance wi the Cuperti o Municipal Code,Chapter 9.12 and the
p H Ith&S e Code tions 55 ,25533,and 25534.
I 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 O mer o nth riz ent:
Compensation laws of California. If,after making this certificate of exemption,I
at
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. ONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
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 Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
-4emnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
s,and expenses which may accrue against said City in consequence of the
�..nting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
C-'C-'ONTIRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: PERMIT# l
OWNER'S NAME. PHONE# (�
GENERAL CONTRAC OR• r BUSINESS ICEN #
ADDRESS: 14 CITY/ZIPCODE:
*Our munici al code requi es all busi esses working in he city to have a City of Cuperti bu iness lice se.
NO BUILDING FINAL OR FINAL OCCUPANCY I ON(S) WILL BE SC UL D UNTIL THE
GENERAL CONTRACTOR AND AL SU O S AYE OBTAINED A CITY F CU E
BUSINESS LICENSE. / 0
r'1
I am not using any subcontractors: l
ignature Date
Please check applicable subcontractors and complete the following information:
j/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
Glass/Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF
is CITY OF CUPERTINO 1011011 7
FURNACE/AC
CUPERTINO PERMIT APPLICATION FORM
APN # .3 Date:
Bu i in A ress:
Owner's Name: . PhO6#:
Contrac r. �L[) (I � A /' Phone #: j 2 U 6 C)
/U � 3l
tJ �� 9 l S S C_ Fax #: I tW 3
Contractor Licen e#: Cupertino Business License #:
Contact: Phone #: ( 931
Kf K I Fax
Building Permit nfo:
Elect� Plumb Mech
Residential Comme cial ❑
Job Descri tion: F CU-o LIE � /R C— _ 1 /--�� S j I k ftl-k AJ ACKl �l� �i t CJ
For Residential Installations:
Attic ❑ 1st floor 2"d 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: Type of Construction (Usage Class):
Strapped ❑ On Platform ❑ Bonded New Location ❑ Replacement
Project Size: Express 9---�Standard ❑ Large ❑ Major ❑
Valuation:
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