10050186 CITY OF CUPERTINO 13UILDING PERMIT
BUILDING ADDRESS: 7921 BELKNAP DR CONTRACTOR:ATLAS-TRILLO HVAC PERMIT NO: 10050186
OWNER'S NAME: HOMER L AND JACQUELYN FLETCHER 1965 KYLE PARK CT DATE ISSUED:05/25/2010
NER'S PHONE: 4082579106 SAN JOSE,CA 95125 PHONE NO:(408)286-8931
LICENSED CONTRACTOR'S DEri
ARATION r r
S
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class C Lic.#
MECH F RESIDENTIAL r— COMMERCIAL
I �
Contracto ��ate l v
I hereby affirm that I am licensed under the provisions of Chapter 9 JOF',DESCRIPTION: REMOVE&REPLACE A/C
(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:$3400
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
permit is issued. API\ Number:36208041.00 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 th of Cupertino against liabilities,judgments, [80 DAYS FROM LAST CALLED INSPECTION.
costs,and expenseV ace against said City in consequence of the
granting of this peional he applicant understands and will comply �^
with all n n-poinlat' s p r the Cupertino Municipal Code,SectionIssued! �-
Signature Date
RE-ROOFS:
OWNER-BUILDER DECLARATION All r)ofs 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 inspcction.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, Sign tture 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 ha-e 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 Cali ornia Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the com 3liance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safe ty Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Add.tionally,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 cont rminants as ne y the Bay Area Air Quality Management District I will
permit is issued. ainta' .compP
with he Cupertino Municipal Code,Chapter 9.12 and the
ealth a 'ons 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 wr or age /,, r�
Compensation laws of California. If,after making this certificate of exemption,I \ Date: 1� 1 `
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 herby 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.1 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 Lens ler's Address
upon the above mentioned property for inspection purposes.(We)agree to save
i-' -nn and keep harmless the City of Cupertino against liabilities,judgments,
an I expenses whic ay calue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this p it. dditio the applicant understands and will comply I un(erstand my plans shall be used as public records.
with all i ion-po* ou a re ati s er the Cupertino Municipal Code,Section
9.18. ��n ( Lice used Professional
Signature Date
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Got:
APN . . . . . . . . : 36208041 .00
DATE ISSUED. . . . . . . : 05/25/2010
RECEIPT #. . . . . . . . . : BS000010483
REFERENCE ID # . . . : 10050186
SITE ADDRESS . . . . . : 7921 BELKNAP DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : HOMER L AND JACQUELYN FLETCHER
ADDRESS . . . . . . . . . . : 7921 BELKNAP
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4973
RECEIVED FROM . . . . : ATLAS-TRILLO
CONTRACTOR . . . . . . . : TRILLD, STEVE LIC # 4269
COMPANY . . . . . . . . . . : ATLAS-TRILLO HVAC
ADDRESS . . . . . . . . . . : 1965 KYLE PARK CT
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408) 286-8931
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 3, 400 . 00 1 .00 0 . 00 1. 00 0 . 00
1BREMAIRHA NO.UNITS 1 . 00 63 .00 0. 00 63 . 00 0 .00
1BSEISMICR VALUATION 3, 400 . 00 0 .50 0. 00 0. 50 0 .00
1MPERMITFE FLAT RATE 1 . 00 42 .00 0. 00 42 . 00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 106 .50 0 . 00 106 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 106 . 50 #2803
---------------
TOTAL RECEIPT 106 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
CITY OF CUPERTINO
RECEIPT NUMBER: BS000010484
RECEIVED BY: PATRICIAG PAYOR: ATLAS-TRILLO
TODAY'S DATE: 05/25/10 REGISTER DATE: 05/25/10
TIME: 14 :45
1
BUSINESS LICENSE TAX RENW - ATLAS-rRILLO $114 .00
----------------
TOTAL DUE: $114 .00
CHECK $114 . 00 REF NUM: #1396
TENDERED CHANGE
$114 . 00 $. 00
10 0
CITY OF C;UPERTINO
FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN �� , J I Date: o C)
u' dinAd ress: T
11 (� (i WE
OErc-='
n4
's Name: Pho
C ntractor• Y J Phone#:� ZQ (Lj�
Fax#: � ��j 1
ontractor Lic nse#: I Cupertino Business License#:
Co tact: Phone#: / 26L
YT� L'-Lb.Rid ) Fax# (? c
Building P rmit Info:
e)
Elect 0 -- Plumb [�� Mech
Residential Comme cial
Job Description:
� '-Rq4Ae,& ,
For Residential Installations:
Attic ❑ 1St floor pl:—Z) 2nd floorAdheretominimum 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 []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
} CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
AIR FURN/AC
CONDITIONING
1BCAIRHAN Commercial A/C Units <= IOk CFM B
1 MCRAA Commercial Mech Rcpair/alt/add M
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
IBSEISMICO Seismic Commercial B
1 PGASCOM Commerical for ea gas piping System P
1-4 outlets
1 PGASRES Residential for ea gas piping system P
of 1-4 Outlets
1 BPGAS For each gas piping system of 5 or P
more per outlet. Comn/Resid
/ 1 BREMAIRHAN Residential A/C units <= l Ok CFM B
1 MRRAA Residential Mech Repair/alt/add M
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
IBSEISMICR Seismic Residential B
1 EPERMITFEE Electric Permit E
' 1MPERMITFEE Mechanical Permit M
1 PPERMITFEE Plumbing Permit P
1 TRAVDOC Travel Documentatio:l B
1BUSLIC Business License B
INPUT Resources Energy IAD/Health
M.Indoor Air Quality and Finishes
1.Use LowMo-VOC Paint 1 IACWHealth pts y=yes 0
2.Use Low VOID,Water-Based Wood Finishes 2 IAO/Health pts y=yes 0
3.Use Low/No VOC Adhesives 3 IAC 2/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAO/Health pts y=yes 0
7.Seal all Exposed Particleboard or MDF 4 IAO/Health. pts y=yes 0
B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0
10.Install Whole House Vacuum System 3 IA 3/Health pts y=yes 0
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0
2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAC/Health pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
1 1 1
Total Points Available: 1 1401 130 57
Total Points Project Received:1 01 01 0
G:datalprogs/greenbuild igguidelines/remodelers/greenpointsfinal2.12.04protected.xls
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
CONTRACTOR / SUB(:ONTRACTOR LIST
JOB ADDRESS: PERMIT#
OWNER'S NAME: PHONE#
GENERAL CONTRA OR: BUSINESS LICENSE
ADDRESS: KV CITY/ZIPCODE:
*Our municipal code req fres all usinesses working in the city to have a City of Cup rtin business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete I he following information:
V SUBCONTRACTOR BUSINESS 74AME 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
Til
_ S
Owner/Contractor Signature Date