07100129 CITY OF CUPERTINO �-r ' j�Q��.TI�N
BUILDING DIV7S10N PERMIT V��� ���� ' ':
: _.. <.
PERMIT NO.
BUIL O f r �r� aES �ESTERN DR VALLEY f:EATING & COOLING 07100129 .
PERMIT ISSUE DATE
IER'S NAME: ,
TILLMAN JESSE L AND MARION C 1171 N 4: TH ST 10/17/2007
SANITARY NO. CONTROL NO.
PHONE:
(408) 29� -6290
BUILDING PERMIT INFO
ARCHITECT/ENGiNEER: BLDG ELECT PLUMB MECH
� � � �
j p � LICENSED CONTRACTOR �ec►.nRnnoN Job Description
%� I hcreby aflirm that I am liccnscd undcr provisions oC Chapicr 9(commencing
: z � aiih Scction 70(M)) of Division 3 of thc Business and Prof C and my liccnsc is RE PLAC EI ) FURNAC E
�� y in full force and effec
j�? Licensc C1 s �� � Lic. #
^ p Datc Contrac
: F '� ^ r A CH[TECI'S DECLARATION
j� . �
a 1 undcrstand my plans shall bc uscd as public rccortis
)yU
' m y Licenscd Profcssionat
: � a OWNER-BUILDER DECLARATION
N �
1 hcrcby af�rtn that I am cxcmpt Gum tLc Camractor's Licrnsc w or thc
� o O (ollowing rcuon. (Sec6oa 7031.5, Business and Profccsiuns Cale: Any city or county
u,°, �i which rcquims a pcanit to consuuc4 al�cr, impmve, dcmolixh, or �epair any swcmrc
prior W i�s issuancc, alsu rcquires Utc applicant far such permit to file a signcd statcmcnl �; q , Ft. Floor Area Valuation
�?< tha� hc is liccnud pursuan� lo t hc pmvision s o[ U u C o n u a c w r' s L i c� c n s c L a w ( C h a p t c r 9 • $ 3 7 1 4
r t �(commencing wiih Section 7000) of Division 3 of Ihe Business and Professions Cade) or
y�.. that he is exempt therctrom and Ihe basis (or the allcged ezemption. Any violation of
Section 7031.5 by a�ry applicant tor a permit subjecu the applicant to a civil penalty of 3 5 9110 0 Number Oeeupaney Type
noc more �han fw hundrcd dollars (5500�
❑ I, u owncr o[ ttie pmperty. or my cmployces with wages u the'v solc compensaGon,
will do thc wark, and the strucium is not intendcd or ufteced for salc (Sec. 7044. Husiness Requ ired Inspections
and Professions Codc: The Conuactor's License Law does not apply to an owner of
property who builds or improves thercon, and who does such work himselCor Uwugh his
own employces. providcd iha� such improvements ue not iniended or otiered for sata 1[.
however, the building or improvement is sold wi�hin one yesr of complcdon, ihe owner-
builder will have the burden of proving it�at he did not build or improvc [or pu�pose af
sak.).
❑ I, as awner of �he property, am ezclusively conuacting wilh limnsed rnnuxtors to
constroct the pcoject (Sec. 7044. Business and ProCcssions Code:) The Contncmfs Li-
ccase [aw docs oot apply a an owncr of property who builds or improves the�eon, and .
w6o convacts [or such projects wi�h a contractor(s) licensed pursusnt eo the Convacror's
License Law.
❑ 1 am ezempt under Sec . B 8c P C far this �cason
�er Date _ . _
WORKER'S COMPENSATION DECLARATION
I Aereby affirm under penalty ot perjury onc of the following declarations:
❑ i hsoe and will main�ain a Cenificam oCConsent to sel(-insucc for Workcrs Compen-
sation, u provided for 6y Section 3700 ot the Labo* Code. (ar �he performance ot the
work for which Wis permit is issucd.
'1 have and will main�ain Worker': Compensation Iasurance, u teyuired by Section .
J oC �he labar Codc. Cor thc performance of the work for which this permit is issued
..�y War Compensa�ion Insurancc carticr and Policy number azc:
Carrier Policy No.:
CERT lCA7'E OF EXEMPTION FRO ORKERS'
COMPENSATION INSURANCE
(ihis secUon need not Ae complctcd i[ the pertnit is kx onc hundred dollus (S 100) ,
or Icss.}
I certi(y thct in thc performancc af thc work for which Uiis pertnit is issucd, t shall nat
employ any person in any manncr so az w bccomc subject ta the Workers' Compcnsatlon
Laws of Califomia. Datc
Applicant
NO'I'iCE TO APPLICANT: If, aftcr making U�is Ccrti�ca�c o( Ezcmption, you should
bccome subjcct to �hc Workcr's Compcnsation provisions of thc Lahor Codc, you must
� O farthwi�h comply with such provisions or this permil shall bc dccmcd awokcd.
Z �"' CONSTRUCTION LENDING AGENCY
[.~-� �- I hccc6y aftirm Wat thcre is a consuuction Icnding agcncy Cor thc perfwmancc uf �
a., � thc work Cor which Utis permit u issucd (Scc. 3097, Civ. C.) ,
LL7 A Lendcr's Namc
a z Lcndtr's Address
V � I certify iha� 1 havc read ihis applieation and s�aic that �hc a6ovc infom�auun is
w ►� cortcct. 1 agrce �o comply with all ci�y and county orefina�ues and sute laws relating to
� U building conswction, and he�eby authori�e represenutivcs of this city to cntcr u�n thc
aAovc-mcntioncd property for inspcc0on purposes.
�' a (Wc) agree to save, indcmni(y and kccp hazmlcss the Ciry of Cupertino against
�� liabiliues, judgmen�s, costs and expenses which may in any way acccue against said City
V z in consequencc oC �he gcanting o( Ihis permit. DaCe
� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by
SOURCE REGULATIONS.
Re-roofs
Signuum af ApplicanUContractor �'� T e of R oof
HAZARDOUS MATERIALS DISCLOSURE YP
Wi111hc applicant or futurc Auilding occupant storc or handle ha-rardous matcrial
dcGncd by thc Cupenino Municipal Code. Chapter 9.12. and [he Hcalth and Safcty
�. Scction 25532(a)? �� All roofs shall be inspected prior to any roofing material being installed.
❑ Ycs � •
wIl the applicant or Cutu building accupant use equipmenl ar dcvices which
If a roof is installed without first obtaining an inspection, I agree to remove
emit harardous air comaminan�t ckfincd by �he Bay Area Air Quality Managcment all new rr aterials OL 1flS ecr' n.
Disuicc?
❑ Ycs Nu
1 havc rcad the ha�ardcws matcrials requircmcnts umlcr Chaptcr 6.95 of �hc Califor- / - �/ �'�
Hcal�h & Safcry Codc, Scctions 25505, 25533 and 25534.1 undcrstv�d that itthc building _ v
.,ocs not curten�l vc a tcn Ihat i� is my responsihilily to rrouCy thc oecupant of thc
rcyuiremcn met rior w issuancc oC a Ccnificatc of Occupanry. S� n$t re _of plicant Date
All roof coverings to be Class "B or better
Ow r o ut �zcd agcnt Datc '
�� , CITY OF CUPERTINO
.. x� _ _ _ ___ _ ____ ---- - ___-- __ ____ _-----
a _ -_ __ _-_ _ _ — __ - - _- ___ _ ������ �'
� ,.� FURI�ZACETAC
��p��T�t�� PERMIT APPI�ICATION FORM
APN # Date:
=S� //L?C��- /D ��?' � �
Building Address: '
(,� r�,S�'�� �-
Owner's Name: Phone #: ='
'� L.. � -�►, � �' $j3
Contract �r: �,� � License #�
U 1� � � � , �- Y-�
Contact: Cupertino Business License #:
��1
Building Pernut Info:
Bld ❑ Elect ❑� Plumb ❑ Mech Ld'
Job Description:
�f' � 1.� I Z C
Residential Commercial ❑
For Residential Installations:
Attic � l floor � 2 floor �
Adhere to min set back re uirement �
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) �
Structural Calculations required for new installation �
New installation Plannin A roval Re uired
Cost of Project: � Type of Constru;,tion: Occupancy group:
l�
Strapped On Platform Bonded Sq.Ft. Floor Area:
New Location � Re lacement �
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Ener BUILDING
BREMFURN f�elocation of Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cfrn MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
. . - --
_----BS�ISIVIICRE___ ---_ _----_ Seismic Fee _ ------ ---_____ BUILDIN ----- _-
EPERMITFEE Elec Pernut Issuance ELECTRICAL
MPERMITFEE Mech Pernut Issuance MECHANICAL
PPERMITFEE Plumbin Permit Issue PLUMBING
BPERMFEE Bld Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC � Business License BUILDING
CITY OF CUPERTINO
5 ITEMS OF 10 PERMIZ RECEIPT OPER.ATOR: suew
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 35�11005.00
DATE ISSUED.......: 10/17/2007
RECEIPT #....•••-•: BSC00003019
REFERENCE ID # •••: 07100129
SITE ADDRESS .....: 10195 WESTERN DR
SUBDIVISION .......
CITY .............: CUFERTINO
IMPACT AREA .......
OWNER ............: TIILMAN JESSE L AND MARION C
ADDRESS ..........: 10195 WESTERN DR
CITY/STATE/ZIP ...: CUFERTINO, CA 95014
RECEIVED FROM ....: VAILEY HEATING
CONTR.ACTOR .......: AT�:INSON, THOMAS LIC # 141
COMPANY ..........: VAI�LEY HEATING & COOLING
ADDRESS ..........: llil N 4 TH ST
CITY/STATE/ZIP ...: SAI� JOSE, CA 95112
TELEPHONE ........: (4C8)294-6290
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
BSEISMICRE VALUATION 3,714.00 0.50 0.00 0.50 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 : 157.73 0.00 157.73 0.00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
204 UNDERFLOOR FRAME 301 ROUGH PLUMBING
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL 514 FINAL PUBLIC WORKS