07100173 CITI' OF CUPERTINO
, BUILD'tNG DIVISION PERMIT CC1�1��AGTt9R I�Y�UR�ATIOIY•; ;:
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BUiLDiNG ADDRESS: PERMIT NO.
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'ER'S NAME:
PHON . i � T T S��/ 2 O O 7 CONIROL NO.
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� BUILDING PERM[T INFO
ARCHIT'ECClENGI NEER:
BLDG �LECT PLUMB MECH
� � 0 �
> Q LICENSED CONTRACTOR'S DECLARATION JOb DeSCT1�1C10❑
�� I hcrcby afGcm that I am licenscd undcr provisions of Chap�cr 9(commcncine
:� wi�h Scction 7000) of Division 3 of ihc Busincss and Profcssiuns Code, and my liccnsc is
� y in full force and eff}� � 30 L/e17Z_ REMOVE F. REPLAC E 1 � �� � � � BTU FURNACE
� ? Licensc Class ` ` � V Lic. #
: p Date �D - Y-y� Conlracwr
: � ARCHITECi'S DECLARATION
" - � 1 undcrstanJ my pians shall bc uscd as public rccords
�<
U
F' Liccnscd Pmfcssional
� a OWNER-BUILDER DECLARATION
� .�
I hcrchy alfirm that t am cxcmp� from thc ConUactors Liccnsc Law for thc
j O following rcazon. (Sccuon 7031.5, Busincss and Profc.ssions Codc: Any city or coun�y
;�i which rcquims a pcimit to conswc4 altcr, improvc, dcmolish, or repair any swcturc
;� prior w its issuancc, alsu rcquircs thc applican� for such permit io filc a signcd statcmcnt
� � that he is liccnscd pursuant to thc pmvisions of thc Contractur's Liccnsc Law (Chaptcr 9 S q. Ft. Floor Area Valuati on
-� (commencing with Scction 7000) of Division 3 of lhc Busincss and Profcssions Codc) or
C.. that he is exempt theccfrom and tAe basis Cor the allcgcd exemption. Any violauon of
Section 7031.5 by airy applicant Cor a permit subjects thc applicant to a civil pcnalty of APN Number Occupaney Type
not more than 6vc hundred dollars (5500).
❑ I, az owncr o( tt�e pmperty, or my cmployces with wages az their solc compensation, 3 6 910 0 3=.. 0 0
will do thc work, and ihe stcucture is not intendcd or oF(ered for salc (Sa.7044, Business Required Inspections
and Professions Code: 77u Conuacwr's Licence Law does not apply w an owner of
property who builds or improves theccon, and who dxs such work himselt or through his
own employecs, providcd tha� such improvemen�s are not in�ended or ollerod for sala IC.
however, the building or improvement is sold within one year o( completion, the owner-
builder will have �he burden oC proving Ihat he did not build or improvc (or pmpose of
salc J.
❑ I, as owner of �he property, am exclusively conuacting with licensed convactors to
wnst�vM Ihe pmjett (Sec. 7044. Business and Profcssions Code:) The Convacmr's Li-
ccnse Law does aot apply to an owner o( property who builds or improves thereon, and .
who conuacts [or such projects wi�h a contractor(s) licensed pursuant to the Convactor's
License Law.
❑ 1 am uempt under Sec , B& P C for �his rcason
:r Dak
WORKER'S COMPENSATION DECLARATION
i hercby afficm under penalty of perjury onc of the following declaraGons:
❑ I hsve nnd will maintain a CeniGcate of Consent lo sel4insure for Workcr's Compen-
sation, as provided for by Sec[ion 3700 of U�e Labor Code, for ihe performance of 1he
worlc tor which Nis permit is iuucd.
❑ I hav� and wi0 maintain Workcr's Compensation Insurana, as icquired by Section
3700 oC the Labor Code, fw the perCormance of the woric for which this pern�it is iscued.
My Workers Compensalion Insurance carrier and Policy numb�e are: �
Cartier: �� _ �^'� J Poliry No.: �1 / �� �
CF,RI7FlCA7E OF EXEMPl'[ON FROM WORKERS'
COMPENSATION 1NSURANCE �
(This section neeA irot be completed if tlx pecmit is for one hunMed dollars (S 100)
or Icss.)
1 ccni(y �hxt in thc performencc of thc work for which �his pertnii is issued, l shall not
employ any person in any manncr so az to becomc subjec� to the Workcrs' Compensation
L.aws o[ Califomia. Datc
Applicant
NOTICE TO APPLICANT: If, aftcr making �his CcniCcatc of Ezcmption, you should
bccome subjcct to tbc Workcr's Compcnsation provisions of thc LsYwr Codc, you muu
� O foMwiW comply with such provisions or this pccmil shall bc dccmcd rewokcd.
i
"'' CONSTRUCTION LENDWG ACENCY
�� 1 herc6y a�rm that there is a consuuction Icnding agency for the performan�x of
;� ihc work for which ihis permit is issucd (Scc. 3097, Civ. C.)
I Q L.endcr's Namc �
� z L.cnder's Addrcss
)
) � I certiCy �hat I havc rcad this applicadon and sia�c that �hc abovc inlortnatiun is
►-� corrcct 1 agrce to comply with all city and county ordinantts and state laws tclating to
j U building conswction, and hcrcby authori�e rcprescntadvcs of ihis city to cn�cr u�n ihc
W abovc-mentioncd property for inspccuon purpaus (
' (We) agrce to save, indcmni(y and keep harmless �hc Cily o[ Cupcnino agains�
�� liabilidu, judgmcn�s, c ts and cxpcnses which may in any way acccuc against said City
) z in consequence of granting of ihis permit.
� APPLICANT ERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 1�j .r Z �J7
SOUR E U TIONS.
"" lU � �� Re-roofs
K ur uanucaiu.ewr �v� -
HAZARDOUS MATERIALS DISCLOSURE Type of Rc of
�11 Ihe appliant or fuwre building occupant storc or handlc ha•rardous matcrial
�icfincd by the Cupertino Municipal Codc. Chaptcr 9.12, and the Hcal�h and SaCcty
, SccGon 25532(a)? �, All roofs s: �all be inspected prior to any roofing material being installed.
❑ Ycs
wll thc applican or fuwrc building occupant usc cyuipmcnt or Jcviccc which
If a roof is installed without first obtaining an inspection, I agree to remove
cmit harardous air contaminants u dcfincd by thc Bay Arca Air Quality Managcmcnl all new ma terials for inspec :IOA.
�ISU;���
❑ Y�
l havc rcad Uu ha� s ma�crials �cquiremcnts undcr Chap�cr 6.95 of thc Califor-
nia Hcal�h & Safcty Codc, Scctions 25505, 25533 and 25534. f undcrsiand �hat i( Uic building
docs rrot curtcnt havc a �cnan4 �ac it is my rcsponsibility w notiCy thc occupam of �hc
rcyuircmcn ;�n m�� x me� P �o� w�u��,� or a c��;r�a� or a�P�ry. Signature c f Applicant Date
� y' All roof coverings to be Class "B" or better
O r or authoroad agcnt Da�c
�; �� 100� 7�
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-y =�: � CIT'�' OF CUPEI�TINO
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CUPEf�TINO ��L��IT APl'Ll CA7 li URM
APN �# Date: ---- ---�
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Buildin� �Address: � r -
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Owner's Na�lle: � Phone #: �
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Eontra��or: ' .� ;= �, , �� Li�ense #:
--� f H -�.E �_ � �� _' �' -, �.�' 1 _ � __ 30 � �f az� ----- -- - --.
Contt:ct: Phone #: ;
_ 1��-L.E P� E�P.s � 7 q-07� a� _— _ �
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ApplicaiiVC��itractor: '
�� �+� �r'� --- ------ --- -- - ---- - -- ---:
_ �
Building Perinit Info: - � �,
Bld Eie � ' _ _ ��� _ _ ����i _ - — � -- -- �
Job Descripti�n -` ��� �
Residen�ial: _ I�C ��Z ���� � �� � ���' "��=ommercial: • _ __ _I
Sq.Ft. Floor �rea: $/Sc1.Ft.: • ;
'lrchitect/Ei�gineer: - - - -- -- -- Vuly�b���� ---------,�
� - -- --;
Type of Cor:struction: Occupancy Group: I
ti� ,
---- ------- ---------------- - —�-------- ------ -:
Qt}�. it
A�licablc: 1=ee 1D ___ __�ee Descri tiun � Fe� Uro�� __
� BENL _ E �er y _ _ _ BUI LIll:\G __
_� .. BREMFURN_______ _ _ R°location �f FLirnac� _MECI-iAN1CAl._ _�
--�— , ',
EMACOV ____ _ A U riit > 10 ,0U� cfm vICC I-IAtti ICA I___�I
' B REMA1RHr� N A /C Uiii <= 10, �OU cfm MEC I-lAi�'I CAI .. ;
�BREMRECLPT R=cptl, S��itch & Ou�lets ELEC'I'I:1CAL___!
-----;-- --- - __
� BSEISM1CRl: S:ismic ��c Res F3UILID\G i
--�--;' ---- - - -- - - ------
EPERMI�I'F E �ec Yeri nit lssuailce LLE CTI:ICAL, I
- — - —�
_�__ � MP�RMITFEE _ _ Iv[ech Per Issuanc MECHA _�
�__ ! PPERNIITFEL ___ _ __P umbin�Pei'iliit I�st�e _ PLU�1B!NG ___.
- - ' BPEk MFLF ---- - -- Bld� P l�ees BUILIll\C - _--
� B P an Clieck F� BUI LID'��(� ��
---- r BUS1 . lC - -------- - -- F3usines� Licensc — f3UILID:�G ----
�_ _ - ------------ ---��--- --- ---- -
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIZ RECEIPT OPER.ATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blk. Lot:
APN ......... 36�10031.00
DATE ISSUED.......: 10/24/2007
RECEIPT #.........: BSC00003070
REFERENCE ID # ...: 07100173
SITE ADDRESS .....: 19�41 LA MAR DR
SUBDIVISION .......
CITY .............. CUF'ERTINO
IMPACT AREA .......
OWNER ............. DA�'E & SUE RANNEY
ADDRESS ........ 19�41 LA MAR DR
CITY/STATE/ZIP ...: CUF'ERTINO CA, 95014-3310
RECEIVED FROM ....: R F'ERLHEFTER
CONTRACTOR .......: PHF;LPS, DALE LIC # 12079
COMPANY ..........: A b: H HEATING
ADDRESS ..........: 77(� CHESTNUT ST
CITY/STATE/ZIP ...: SAP� JOSE, CA 95110
TELEPHONE ........: (4(ig)279
FEE ID UNIT QUANTITY ��'IOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- --�-------- ---------- ---------- ----------
BENERGY PERMIT FEE 1.00 34.86 0.00 34.86 0.00
BREMFURN NO UNIT 1.00 14.31 0.00 14.31 0.00
BSEISMICRE VALUATION 4,700.00 0.50 0.00 0.50 0.00
EPERMITFEE FLAT RATE 1.00 40.79 0.00 40.79 0.00
MPERMITFEE FLAT R.ATE 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 : 172.04 0.00 172.04 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 172.04 MC
---------------
TOTAL RECEIPT : 172.04
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) 777-3228
CIIY OF Fax (408) 777-3333
CUPEi�TiNO
Buildi:n De artment
JOB D R SS: PERMIT #
l� ��� �� � ��- � ������ �
OWNER'S NAME: ,/�wNr-� PHONE # 2�� - �G� Z L
GENERAL CONTRACTOR: �-� � rL.._ FAX #
,
I am not using any subcontractors: " r � ~ � ^. � ��� Z` � �' 1
Si�;nature Date
Please check a licable subcontractors and com >lete the followin information:
SUBCONTRACTOR BUSIrfESS 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'
------� ----- � .__ _ /�j- ? ��- v �
Owner/Contractor Signature Date