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07100203 CITY OF CUPERTINO ` ` ` '` ` SUILDING DIVISION pE�T ��T�� TO�: : ,.,. .:.,_ ...:;r;: .;:;.:_ ... ..::.:::::: .:... . . ._ ....:.:.. ... .,::- : BUILD N AD RESS: PERMITNO. ��1b9 CASS PL ATLAS—T]ZILLO HVAC 07100203 . ;ER'S NAME: PERMIT LSSUE DATE KOZEN ROY K AND SYLVIA I 1965 KY: �E PARK CT 10/29/2007 PHONE: SANiTARY NO. CONTROL NO. (408)285-8931 ARCHiTECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH � � 0 � i p Q LICENSED CONTRACI'OR'S DECLARATION IOb D6SCflpt1011 � V� I hcrcby affirm ihat I am liccnscd undcr provisions of Chaptcr 9(commcncinS ; Z, � with Scc�ion 7000) of Division 3 of thc Busincss and Profcssions Code and my liccncc is R&R FUR] JAC E& ADD A/ C ?� y in fuli forcc and clfe j � � ? Licensc C ss ��• � : F [ p pa� Contractor � ARCHRECI'S DECLAR N i a Q I undcrs�anJ my plans shall bc used as pubiic rccords 1yU ' 4. y Licensed Pcukssionai � y � OWNER-BUILDER DECLARATION >' I hcrcby aCfirm �hnt 1 am cxcmpt from thc Contractar's Liccnsc Law for �hc j p O following rcason. (Section 7031.5, Busincss and Profcssions Codc: Any city or county �,°, � which rcquires a pcmiit to conswct, altcr, improvc. dcmolish, or repair any stmcturc � Z� prior to i�s issuancc, also rcquires ihc applicant for such pertnit to filc a signcJ s�aicmcnt Valuation �_ � ihai he is liccnscd pursuant to thc pmvisions oC thc Con�ruu�r's Liccnsc Law (Chaptcr 9 ; iq. Ft. Floor Area r � F- �(commencing with Section 7(l00) of Division 3 a( ihe Businecs and Professions Code) ar �T 9 � � � ,u, �.. that he is ezempt theicfrom md the bazis Cor t�e allegcd exemption. Any violation of Secdon 7031.5 6y arry applicant Cor a pertnit subjects U�e applicant to a civil penalty of Number Oeeupaney Type not more than fivc dundred dallars (5500). 3 r J 7 � 1 � 4�� ❑ I, as owner o[ tt�e property, ar my cmployces with wages u the'v solc compensadon, will do che work. ar.d �he structure is noi inteaded or offeced for sale (Sec.7044, Business Re uired Ins ections and Professions Code: The Contractor's License Law does �rot apply to an ownu o( Q p property who builds or improves thueon, and who does such worlc himultor Uuough his owa emplayces, providcd �hat such improvemen�s are not intended or o[tered Cor sak. IC. however, the building or improvement is sold within one year o[ completion. �6e owner- builder will have the burden oC proving �at he did not 6ui1d w improvc [or pucpox of sateJ. ❑ I. as owner of the propeny. am exclusively conuacting wi�h ti«nsed contractors a consuuct ehe project (Sec. 7044. Susiness and Professions Code:) The Coauaewr's Li- ccnse [aw docs not apply to an owner of property who builds or improves �Aneon. and , who wn�racts [ar such projeas with a camractor(s) licensed pursuam to �he Conuxtor's License Law. � I am ezempt under Sec. . B& P C for this m.ason u: Date _ . WORKER'S COMPENSATION DECLARATION I hercby sfiirtn under penalty o[ perjury one a( the following declarriions: ❑ I hsre and will maimain a CeniGcate o[ Cantent to sclf-insure far Workcrs Compen- sation, as provided for by Section 3700 oC Uu [abor Cade. [or the performance o( the woric for which Nis pertnit is issued. ❑ I have and will maintain Worker's Compensalion Insurance, az required by Section 3700 0( the Labor Code, for ihe pertormance o( �he work (or w6ich this permit is iscued. My Worke�C pensation�ucancc 'cr and Poliry nu ber arc: p � Cartier. � � Potiry No.: � ! CERTIF[CATE OF EXEMPI70N FROM WORKERS' COMPENSATION INSURANCE ([his seclion necd not bc comple�cd if the permit is for anc hundred dotlars (S I00) o� Icss.) � I ccnify that in thc perfortnancc af thc work fw which �his permit is issucd. l shall not employ any person in any mmncr so az w bccomc subject ta the Warkcrs' Compensation Laws a(Califomia. Datc AppGcant NOITCE TO APPLICAM: lf, aftcr making �his Certificatc of Excmplion, you should bccome subjcct to thc Workcr's Compcnsation provisions af ihc Lalwr Cadc. you must � O fonhwi�h comply with sueh provisions or this permi� shall bc deemcd rewkcd. r-. CONSiRUC?lON LEND[NG AGENCY � r� 1 hcrc6y a[iirm that thcre is a conswction Icnding agcncy Cor thc perCamamx uC . �.Y, � �hc wurk Cur which Utis pertnit is issucd (Scc. 3097. Civ. CJ W Q Lendcr's Namc ' � z C.ender's Address (� 0 1 ccrti[y �hat 1 have rcad this apptieation and sutc that �hc abovc informatiun is w � cartcct. 1 agree to comply with all ci�y and county orJinances and su�e laws cela6ng to � J building conswction, and hercby authori�e representativcs of ihis city to cntcr upon thc � a above-meniiuned properry (or inspecaon purposes. (We) agree to save, indemni(y and kccp harmless ihc Cily o( Cupcnino against �� liabilities, judgmc , co and ezpenscs which may in any way accruc agaiast said City U z in consequcnc �hc g ting of this permit. �) �� ►� APPLICA �E TANDS AN ILL COMPLY W1TH ALL NON-POIM Issued by: Date �(/ SOURCE U N g Re-roofs � Signawrco �canuComractor �'� Type of Roof ' C ' / HAZARDOUS MATERIALS DISCLOSURE Will thc applicant or (uturc building occupant storc or handlc ha•rardous ma�crial lcfincd by thc Cupenino Municipal Codc. Chaptcr 9.12, and thc Hcalih and Safcty ,�. Scction 25532(a)? All roofs �hall be inspected prior to any roofing material being installed. p va o . Will the applicant o fuwre building occupant use equipment or dcvices wfiich If a roof i:> installed without first obtaining an inspection, I agree to remove cmit harardous air comaminan at fincd by lhc Bay Arca Air Qualiry Managcmcnt all new m aterials for inspecrion. o�s�ri�� O Y� t havc rearl the hvarGous matcrials requircmcn�t undcr Chap�cr 6.95 of ihc Califor- nia Hcalih & Safci Codc, Scctions 25505, 25533 aiu125534. f undcrstand ihac iCiAe huilding docs not c y avc a tcnant, that it is my responsibiliry to �rotify thc occupant af �he rcyuirem w� h must bc or io issuanu oca Ccnifica�c o � Signature of Applicant Date �� p �� _ All roof coverings to be Class "B" or better Owncr or authorizcd a . CITY OF C'UPERTINO �� ` �`��.1��`�:/�.� ,LJPEf�TINO PERMIT APPL�[CATION FORM APN # �, � Date: ��_ � � �� U /D �f (.�, Oa Building Address: � � Q � , Owner's Name: ho #: „ � ----�'�'� � ---- f� � �-SS = �b� C;o tr� ctor: � Pl�c�n :- �ice se : ��r- � . v �� 3�-oS�� `� Co tact: Phone: Cupertino Business i en e#: �� Building Permit Info: Bldg ❑ Elect 0' F lumb C�---- Mech Job Description: �� C � ,- � /� J � - c li( �. Residential Commercial ❑ For Residential Installations: Attic � 1 St floor � 2" floor � '�.dhere to min set back requirement � or Commercial Installations: Replacement same weight ❑ Additional weight (s �]ctural calcs) � Structural Calculations required for new installation New installation Planning Ap roval Required ❑ Cost of Proje .� D � Type of C� ction: Occu ancy group: Strapped ❑ On Platform Bonded � Sq.Ft. Floor Area: New Location � Replacement � Qty. if Applicable Fee ID Fee Description Fee Group BENERGY Eiiergy BUILDING BREMFURN Fi�rnace MECHANICAL BREMACOVER A,'C Unit > 10,000 cfm MECHANICAL / BREMAIRHAN A,'C Units <= 10, 000 cfin MECHANICAL /° BREMRECEPT R�cptl, Switch & Outlets ELECTRICAL BSEISMICRE S�;ismic Fee Res BUILDING BSEISMICOM S�;ismic Commercial BUILIDNG EPERMITFEE E: ec Permit Issuance ELECTRICAL MPERMITFEE M ech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING BPERMFEE B' d Permit Fees BUILDING BPLANCHK Plan Check Fee BUILDING BPG�4S Gas Piping System Fee PLUMBING BUSLIC B.zsiness License BUILDING CITY OF CUPERTINO H ITEMS OF 8 PERMI�' RECEIPT OPERATOR: patg _ COPY # : 1 Sec: Twp: Rng: Sub: Bl}:: Lot: APN ......... 35''01040.00 DATE ISSUED.......: 10,'29/2007 RECEIPT #.......... BS()00003111 REFERENCE ID # ...: 07:_00203 SITE ADDRESS ..... 10:_69 CASS PL SUBDIVISION ....... CITY .............. CU]'ERTINO IMPACT AREA ....... OWNER ............: KO��EN ROY K AND SYLVIA I ADDRESS ...... 10:_69 CASS PL CITY/STATE/ZIP ...: CU]'ERTINO CA, 95014-2751 RECEIVED FROM ....: AT]�AS - TRILLO CONTRACTOR .......: TR:=LLO, STEVE LIC # 4269 COMPANY ..........: AT]�AS-TRILLO HVAC ADDRESS ....... 19�i5 KYLE PARK CT CITY/STATE/ZIP ...: SAId JOSE, CA 95125 TELEPHONE ........: (4i)8)286 FEE ID UNIT QUANTITY ��MOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- -�--------- ---------- ---------- ---------- BENERGY PERMIT FEE 1.00 34.86 0.00 34.86 0.00 BREMAIRHAN NO.iTNITS 1.00 10.26 0.00 10.26 0.00 BREMFURN NO UNIT 1.00 14.31 0.00 14.31 0.00 BREMRECEPT NO. OUTLETS 1.00 1.20 0.00 1.20 0.00 BSEISMICRE VALUATION 9,000.00 0.90 0.00 0.90 0.00 EPERMITFEE FLAT RATE 1.00 40.79 0.00 40.79 0.00 MPERMITFEE FLAT RATE 1.00 40.79 0.00 40.79 0.00 PPERMITFEE FLAT RATE 1.00 40.79 0.00 40.79 0.00 ---------- ---------- ---------- ---------- TOTAL PERMIT : 183.90 0.00 183.90 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 183.90 #9053 --------------- TOTAL RECEIPT : 183.90 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 301 ROUGH PLUMBING ' 303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL � . . ` Community Development ��, 10300 Torre Avenue �� ' � Cupertino CA 95014 Telephone (408) ?77-3228 CIIY OF Fax (408) 777-3333 CUPEI�TINO Buildin De artment JOB ADDRESS: PERMIT # 0 q � QG2 `7�b �-'�-O� OWNER'S NAME: o� PHONE # 3- I6�2� GENERAL CONTRACT R: /-�- - � � , � �//-� � FAX # ' s I am not using any subcontractors: � °ZT� Si gnatur Date Please check a licable subcontractors and com lete the followin information: SUBCONTRACTOR BUSIlJESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing IIectrical 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 T' � U C actor Signature Date