09070157 CITY OF CUPERTIN O BUILDING PERMIT
BUILDING ADDRESS: 22652 SILVER OAK LN CONTRACTOR:RESIDENTIAL HEATING PERMIT NO:09070157
AND A/C INC
OWNER'S NAME: JACK BAUER 605 CRISTICH LN DATE ISSUED:07/22/2009
ER'S PHONE: 4088721240 CAMPBELL,CA 95008 PHONE NO:4083774073
❑ LICENSED CONTRACTOR'S DECLARATIONC� ��
�OYS� 3UILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# --- ri f—
,� MECH RESIDENTIAL COMMERCIAL
Contractor–�1(Jk�f[T1G�\� a
1 hereby affirm that I am licensed under the provisions of Chapter 9 IOB DESCRIPTION:REPLACE EXISTING FURNACE&A/C-
(commencing with Section 7000)of Division 3 of the Business&Professions .ZESIDENTIAL
Code and that my license is in full force and effect. MATING AND A/C INC RENEWED BUS LIC
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.
I have and will maintain Worker's Compensation Insurance,as provided for by ;iq,Ft Floor Area: Valuation:$10280
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
.\PN Number:34249003.00 Occupanc Type:
APPLICANT CERTIFICATION T—7
1 certify that I have read this application and state that the above information is
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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18• Q t, ssued by: Date:
Signaturet v w� Date
OWNER-BUILDER DECLARATION RE-ROOFS:
\II roofs shall be inspected prior to any roofing material being installed. If a roof is
1 hereby affirm that I am exempt from the Contractor's License Law for one of nstalled without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: nspection.
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044, ,iignature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
performance of the work for which this permit is issued. oompliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by iafety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this additionally,should 1 use equipment or devices which emit hazardous air
permit is issued. .-ontaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
1 certify that in the performance of the work for which this permit is issued,I shall fealth&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I )war or t_ �homed agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must �- v t/L— Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION hereby affirm that there is a construction lending agency for the performance of work's
I certify that 1 have read this application and state that the above information is or which this permit is issued(Sec.3097,Civ C.)
correct. I agree to comply with all city and county ordinances and state laws relating ender's Name
to building construction,and hereby authorize representatives of this city to enter
ups"the above mentioned property for inspection purposes.(We)agree to save ender's Address
i :ity and keep harmless the City of Cupertino against liabilities,judgments,
co..__.and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section understand my plans shall be used as public records.
9.18.
Accused Professional
Signature Date
CITY OF CUPERTINO
8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk : Lot :
APN . . . . . . . . : 34249003 . 00
DATE ISSUED. . . . . . . : 07/22/2009
RECEIPT # . . . . . . . . . : BS000008244
REFERENCE ID # . . . : 09070157
SITE ADDRESS . . . . . : 22652 SILVER OAK LN
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : JACK BAUER
ADDRESS . . . . . . . . . . : 22652 SILVER OAK LN
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5633
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 AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 10, 280 . 00 1 . 00 0 . 00 1 . 00 0 .00
1BSEISMICR VALUATION 10,280 . 00 1 . 10 0 . 00 1 . 10 0 .00
1BUSLIC FLAT RATE 1 . 00 114 . 00 0 . 00 114 . 00 0 . 00
1EPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
1MPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
1MRRAA UNITS 2 . 00 126 . 00 0 . 00 126 . 00 0 . 00
1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 410 . 10 0 . 00 410 . 10 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 410 . 10 #26106
---------------
TOTAL RECEIPT 410 . 10
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
S-7
CITY OF CUPERTINO
FUWiACE/AC
CUPEkTiNO PERMIT APPLICATION FORM
APN # 3q,-) q q
0 v � �� Date:Buildin Address:
Owner' Name: Phone#: I �, lO
Ci'" (2)-1Z- `�-'1
C ntractor: LL t Phone#:
i clew h a( Alda f 1 v;) 9 latc, , r1C Fax#:
Contractor License#: Cupertino Business License#:
rl�s sem-('
Contact: Phone#: •3-1-� -�IU�3
Hu\-1 Fax #:
Building Permit Info:
Elect rsw Plumb El' Mech
Residential Commercial ❑
Job Descri tion:
For Residential Installations:
Attic ❑ 1St floor [l 2°d floor ❑
Adhere to minimum setback requirement
For Commercial Installations:
Replacement same weight QP 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 ❑ Bond(-.d New LocationEl Replacement
Project Size: Express Standard ❑ Large [] Ma'or❑
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 C UPERTINO
FURNA.CE/AC
OF
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
AIR FURN/AC
CONDITIONING
1 BCAIRHAN Commercial A/C Units <= I Ok CFM B
1 MCRAA Commercial Mech Repair/alt/add M
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICO 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. Comm/Resid
IBREMAIRHAN Residential A/C units <= IOk CFM B
IMRRAA Residential Mech Repair/alt/add M
1BCBSC Cal Bldg StandakS Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
f
I EPERMITFEE Electric Permit E
i 1 MPERMITFEE Mechanical Permit M
I PPERMITFEE Plumbing Permit P
I TRAVDOC Travel Documentation B
1 BUSLIC Business License B
Community Development
10300 Torre Avenue
'. Cupertino CA 95014
Telephone(408)777-3228
CIV OF Fax(408)777-3333
,XPEkTINO
Building Department
JOB ADDRESS: PERMIT #
w� S 1 0 l� D//f--7
OWNER'S NAME: 6XC-t— PHONE # O
GENERAL CONTRACTOR: a #
I am not using any subcontractors: `L �-
Si E nature Date
Please check applicable subcontractors and com-:lete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
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