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10080069 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10727 RANDY LN CON'rRACTOR:RESIDENTIAL HEATING PERMIT NO: 10080069 AND A/C INC `WNER'S NAME: PEGGY&TERRY GRIFFIN 65 C1tISTICH LN DATE ISSUED:08/10/2010 CAN PBELL,CA 95008 PHONE NO:4083774073 NNER'S PHONE: 4089961149 LICENSED CONTRACTOR'S DECLARATION BUI C.DING PERMIT INFO: BLDG ELECT r PLUMB L License C C10Lie.# MECH r— RESIDENTIAL r COMMERCIAL Contractor der the provisions of Chapter 9 JOE DESCRIPTION:ADDING A/C 3-TON I hereby affirm that I am licensed unp (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, :t Floor Area: Valuation:$4090 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 which this APP(Number:31602041.00 Occupancy Type: permit is issued. 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 WITHIN 18P PAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAY OM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply Date: with all non-point source regulations per the Cupertino Municipal Code,Section Iss,ted by: v 9.18. c c:?mAure Date RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is 13 OWNER BUILDER DECLARATION ins ailed 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 ins)ection. 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) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE I hereby affirm under penalty of perjury one of the following three declarations: I 1 ave 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 Ci lifornia Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the co mpliance 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 contaminants as defined by the Bay Area Air Quality Management District I will in tintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. H-alth&Safety Code,Sections 25505,25533,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,v er qr au_thorized agent: � Compensation laws of California. If,after making this certificate of exemption,I Date: 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. CONSTRUCTION LENDING AGENCY I rereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION f<r 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 11 the above mentioned property for inspection purposes.(We)agree to save ;nnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION its,and expenses which may accrue against said City in consequence of the granting of s permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non int source regulations per the Cupertino Municipal Code,Section 9.18. t� I icensed Professional Date Signature U l? CITY OF C UPERTINO ( 0 (; � (�'\C) l FURNACE/AC CUPS OF PERMIT APPLICATION FORM APN # p V i Date: 1 0 I CJ,^� of 1 Building Address:,QW ner's Name: Phone#: �, 1 LA 11 (Ov- C\ Contra t r: Phone#: 6e f'-)A--vx4cc Fax#: 1� Contractor License#: Cupertino Business License#: 2i C Phone#: ontact: Fax#: Building Permit Info: Elect Plumb ❑ Mech Residential 91 Commercial ❑ Job Description: For Residential Installatio s: 2nd floor ❑ Attic 1:11St floor ❑ Adhere to minimum setback requirement ❑ For Commercial Installations: �.dditional weight(structural calcs) El Replacement same weight ❑ 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 ❑ Standard ❑ Large ❑ Major❑ Valuation: Building Checklist & attach it to the Green Building: Please complete relevant portion of the Green g application or if applicable, include in plan set & the sheet index. Revised 01/07/09 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 7 DATE: 08/10/2010 REVIEWED BY: gs APN: BP#: *VALUATION: Iso *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY 107111, APPLICATION 1 RMAP2 USE: SFD or Duplex F COR"110-, TYPE: as CO 3 � APPLIANCE/EQUIP TYPE FEE ID QTY BP FEES A/C Units (<=10K cfm) 1BREMAIR 1 $63 TOTALS: $63.00 Mech.Plan Check 0.0 hrs $0.00 Mech.Permit Fee: IMPERMIT Other Mech.Insp. 0.0 1 hrs 1 $42.00 e,/; , ��,� ,; t, ,;, t�;���; 1r;�p>. T-1 —1 NOTE. Theseees are based on the preliminary information ava Mable and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS (Fee Resolution 09-051 t:f: 7%1/09) FEE QTY/FEE MISC ITEMS Ylun C6 cu/, Fc ce Stipp[ /'C I'eco PME Plan Check: $0.03 Perim" Suppl PME Unit Fee: $63.00 PME Permit Fee: $42.03 1�r,tfttrroi 1?c iE Work Without Permit? Q Yes 0 No $0.00 Travel Documentation Fee: ITIM VDOC $42.00 7°e, , Select an Administrative Item 131db Stds Commission Fee: $O.CO SUBTOTALS: $147.0 0 $0.00 TOTAL FEE: $147.00 Revised: 8/06/2010 CITY OF CUPERTINO 4 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk: Iot: APN 31602C41 .00 DATE ISSUED. . . . . . . : 08/10/ 2010 RECEIPT #. . . . . . . . . BS000( 11141 REFERENCE ID # . . . : 10080069 SITE ADDRESS 10727 RANDY LN SUBDIVISION . . . . . . . CITY CUPER"INO IMPACT AREA . . . . . . . OWNER PEGGY & TERRY GRIFFIN ADDRESS . 10727 RANDY LN CITY/STATE/ZIP . . . : CUPER'PINO, CA 95014 RECEIVED FROM RESIDENTIAL HEATING CONTRACTOR CATHY HAIRE LIC # 21161 COMPANY . . . . . . . . . . : RESIDENTIAL HEATING AND A/C IN ADDRESS : 65 CRISTICH LN CITY/STATE/ZIP . . . : CAMPBELL, CA 95008 TELEPHONE . . . . . . . . : 4083774073 FEE ID UNIT QUANTITY AMCUNT PD-TO-DT THIS REC NEW BAL ___ ---------- -- ------- ------------- ---------- ---------- 1BCBSC VALUATION 4, 090 . 00 1. 00 0 .00 1. 00 0 .00 1BREMAIRHA NO.UNITS 1. 00 63 . 00 0 .00 63 . 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 4200 ------0_00 ----- TOTAL PERMIT 148 . 00 0 .00 148 . 00 0 . 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION __ _ -------- ---------------------------- -- ---------- 301 ROUGH PLUMBING 303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY 502 FINAL PLUMBING ENERGY 503 FINAL MECHANICAL ENERGY 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL W03-4:)IA031ZIMMM — { CD_-7d,-7 _ f CA . _ _ ! ! i 1 i t i ! � t > . i _ ! I ! ! I' r { C i V V _ E --- t t 1 i a_.- 1 1 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408) 777-3228 5 CITY OF Fax(408)777-3333 ;UPE�TINO Building Department JOBADDIKESS t� L" Mo #©d?0)6/ OWNER'S NAME:J C f Y ' r i fin PHONE # GENERAL FAX # I am not using any subcontractors: Sigr ature Date Please check applicable subcontractors and com lE to the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electricals Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass / Glazing 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