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09070210 CITY OF CUPERTIN O BUILDING PERMIT BUILDING ADDkESS: 21739 TERRACE DR CONTRACTOR:SAN JOSE AIR PERMIT NO:09070210 CONDITIONING,INC. 0—NER'S NAME: ROBERT WARD 1045 C N 10TH ST DATE ISSUED:07/31/2009 U.,NER'S PHONE: 4082574578 SAN JOSE,CA 95112 PHONE NO:(408)286-2047 ❑ LICENSED CONTRACTOR'S DECLARATIONI BUILDING PERMIT INFO LDG re ELECT PLUMB License Class Lic.# 759 MECH � RESIDENTIAL COMMERCIAL� Contractor (�� /Y . Date /�/ I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:FURNACE CHANGE-OUT,COIL CHANGE- (commencing with Section 7000)of Division 3 of the Business&Professions OUT,NEW PUC DRAIN Code and that my license is in full force and effect. AND DRYWELL 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 Sq.Ft Floor Area: Valuation:$4575 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. IAPN Number:35617013.00 Occupancy Type: APPLICANT CERTIFICATION I 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 reg ions per the Cupertino Municipal Code,Section 9.18• Issued Date: Si e Date ❑ OWNER-BUILDER DECLARATION RE-ROOFS: 411 roofs shall be inspected prior to any roofing material being installed. If a roof is 1 hereby affirm that 1 am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 1,as owner of the property,or my employees with wages as[heir sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date: Business&Professions Code) 1,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 I 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 I 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. ,ompliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should 1 store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this ikdditionally,should 1 use equipment or devices which emit hazardous air permit is issued. :ontaminants as defined by the Bay Area Air Quality Management District 1 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 Health&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 riz ent: 7 -5 become subject to the Worker's Compensation provisions of the Labor Code,I must 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 I 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 Lender's Name to building construction,and hereby authorize representatives of this city to enter or e above mentioned property for inspection purposes.(We)agree to save Lender's Address in%- ify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO *' FURNACE/AC CUPERTINO PERMIT APPLICATION FORM APN# 261-p ( i �j. v Date: 7, 30 0 Building Address: Own � �'s Name Phone#:mw 0 Jlsl*,;I f Contractor: 5)90 X105 i5' A11L 60'?d •1._D j'V j� ' Phone#: �OD�%Z Xd Fax#: Contractor License#: Cupertino Business License#: go�q-739 o?, V7Y3 Contact: Phone #: y�� 6� U Y7 f '1 Fax#: Z•30 Building Permitjnfo: Elect� Plumb Mech Residential X Commercial ❑ Job Description: TZ,,v-,tix,,c.c- Ulna-v`a,` — 0,- r ) CU 1 e —v 06w 90(1 'D�rtikV-' For Residential Installations: Attic ❑ 1"floor% 2"d floor ❑ Adhere to minimum setback requirement J~ 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 ❑ Bond(;d New Location❑ Replacement Project Size: Express d Standard ❑ Lar e[] 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 A F FURNA►CEAC CUPEkTINO FEE SCHEDULE Quantity Fee ID Fee Description. Fee Permit Type Group AIR FURN/AC CONDITIONING 1 BCAIRHAN Commercial A/C Units<= l Ok CFM B 1 MCRAA Commercial Mec i Repair/alt/add M 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES IBSEISMICO Seismic Commer,;ial B 1PGASCOM Commerical for ea gas piping System P 1-4 outlets 1PGASRES Residential for ea gas piping system P of 1-4 Outlets 1 BPGAS For each gas piling system of 5 or P more per outlet. C'omm/Resid 1 BREMAIRHAN Residential A/C t nits<= I Ok CFM B 1 MRRAA Residential Mech Repair/alt/add M 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residential B IEPERMITFEE Electric Permit E r 1MPERMITFEE Mechanical Permit M 1PPERMITFEE Plumbing Permit P I TRAVDOC Travel Documentation B 1BUSLIC Business License B CITY OF CUPERTINO 7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk.: Lot : APN . . . . . . . . : 35E17013 . 00 DATE ISSUED. . . . . . . : 07/31/2009 RECEIPT # . . . . . . . . . : BSC00008320 REFERENCE ID # . . . : 09C70210 SITE ADDRESS . . . . . : 21',39 TERRACE DR SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : ROE,ERT WARD ADDRESS . . . . . . . . . . : 21;39 TERRACE DR CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4742 RECEIVED FROM . . . . : SMI JOSE AIR CONDIT CONTRACTOR . . . . . . . : WILLIAM GENTILE LIC # 24783 COMPANY . . . . . . . . . . : SMI JOSE AIR CONDITIONING, INC ADDRESS . . . . . . . . . . : 1045 C N 10TH ST CITY/STATE/ZIP . . . : SMI JOSE, CA 95112 TELEPHONE . . . . . . . . : (4C8) 286-2047 FEE ID UNIT QUANTITY 1,MOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- -- -------- ---------- ---------- ---------- 1BCBSC VALUATION 4, 575 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 4, 575 . 00 0 . 50 0 . 00 0 .50 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 295 . 50 0 . 00 295 .50 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 295 .50 #1454 --------------- TOTAL RECEIPT 295 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL Community Development 10300 Torre Avenue ' Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 CUPEI�TINO Building Department JOB ADDRESS: PERMIT # '-) T7 Dr (f) t6 TO,2 U OWNER'S NAME: , , jze PHONE # o " ' 'Z01/7 GENERAL CONTRACTOR: FAX # I am not using any subcontractors:C49� 5 'LQ WERE Signature ate Please check applicable subcontractors and complete 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