07110075 CITY OF CUPERTINO �����������������+ ;
:�UILDIN� DIVISION PERNIIT ;.. �: .:
- ; ,,::.._._.
_ ;.:. _.: :
PERMIT NO.
BUILDINGADDRESS: ATLAS HVAC 07110075
11011 NORTHSKY SQ "
PERMIT LSSUE DATE
�NER'S NAME: .
NANCY HOLSWORTH 1965 KYLE PARK CT 11 1 2007
SAMTARY NO. CONTROL NO.
PHONE:
BUILDING PERMIT INFO
ARCHI'IECC/ENGINEER: REMOVE & REPLACE FURNACE BL�c E�.ec�' r�.uMa MECH
� 0 � 0
u p p LICENSED CON7'RAC1'OR oecuannoN Job Description
� I hacby aflirm �hat I am licenscd undcr provisions oC Chapur 9(commcncing
� z� wiUi SecGon 7000) o[ Division 3 of the Businest and ProCcuions Code, end my license is
�� y in full Coree and
� v� Z Licensc C1 s ConlracWr
y �, � Da�c
ARCHITECI'S DECLA N
��< 1 undcrstand my plans sAall bc used u public rccards
�yU
` 0 y Liccnsed Profcuional
y � OWNER-BUILDER DECI.ARATION
+� I hcrc6y aRrm �at 1 am excmpt Crom thc Coniractor's Liccnsc Law for thc
i O O following macon. (SccGan 703I.5, Busincss and Professions Codc: Any ciry or rnunty
y� Pi which rcqui[cs a pcnnit to consuuc� alter, improvc, dcmolish, or repuir any swcturc
��o� a��c issuanco, alsu rcquires U�c applicant for such permit to filc a signcd summem y , Ft. Floor Area Valuation
-^< that hc is licensc d punuan t to � h c provi si o n a o! t h c C o n u a c t o r s L i c c n s c L a w ( C h a p t c r 9 S
y F$(commcncing wi�h Scction 7000) of Division 3 af dic Busincss and Profcuions Codc) or
y�., that he ia exempt therefrom and tAe basis �or the allcgcd eumpGon. Any vioiation ot Occupancy Type
Section 7031.5 by siry appiicant Cor a permit sabjecu �he appiicant w a civii penaity of ppN Number
not more than fiw hundred doilars (5500�
❑ I. u ownec o[ the property. a my employces with wagea ss the'u solc compensatlon,
will do the work. end Ihe st[uc[uee is notintended or oftered for salc (Sec• 7044 Business Required Inspections
and Pmfessians Code: '[he Conuacar's Lianse Law dces not aPP�Y e��'� of
propeny wha builds or improw�s �hereon. and who das such wodc himaelf or thmngA hia
own employces. provided that such improvemen�s ue not imended or offered Cor sale. l[.
hawever, the building or impcovement is sold wiihin one year of compleUon, ihe owner
builder will have the burdee u( Proving Idat he did not build or improve for purpose of
sale.).
❑ I, u oaner of �he property, am exclusively conuacting with ticensed rnnvactors a
conatnut the p�njm (Sec. 7044. Business and Professions Code:) The Convanw's Li-
cense [aw docs not apply tu an ownu of proPerty who buiids or improves �hemon, and ,
who conuac�s for such projects with a contnctor(s) Gcensad pursusnt w �he Convactor's
Licenae Law.
I [ am exempt unda Sec. . B& P C for �his rcawn
�� Dste
WORKER'S COMPENSATION DECLARATION
I hercby afCirm under penalty ot perjury onc of ihe follawing declarations:
ye and will maimein a Cenificate of Consenl to ulf-insure (or Workcrs Compen-
ian, u providcd (or by Sectian 3700 0( the Iabor Code• for the P��ort"an� of �Ae
work for which this permit is issued.
I havc �nd will mainitin Workcr's Compensalion Insurance, az �cquired by Scction ,
00 of �hc Labor Codc. Cor thc performance a( �he worlc for which �his pecmit is issued
My Worker'a ompensacion Inwrancc rticr aed Poliry number arc- �
Cartier. Pol'�cy No.:
C TI CATE OF EXEMP170N FRO 0 CERS' ,
COMPENSATION INSURANCE
('►'his scctian necd not bc complc�ed it the permit is for anc hundred dollus (5100) ,
or Icss.)
I cenify that in thc performancc of Uic work for which �his permit is issucd, l shall not
anploy any person in any manncr so as to bccomc wbject to ihe Workcrs' Compensauan
Laws of Cslifomia Date
Applicant
NOTICE TO APPLICAM: If, aMr making �his CcniGca�e of Excmption, you sAould
become subject w thc Workers Compcnsation provisions o[ U�c Lsbor Codc, you must
� O forthwith comply wilh such provisions or this permit shail bc dccmcd revokcd.
Z ►-� CONS7RUCCION LENDING AGENCY
F . N •. I hc�cby a�rm �hat there is a consuucdan Icnding agcncy (or thc pertortnancc uf �
a� ihe work Cor which this permit is iuued (Scc. 3097. Civ. C.) .
LLl Q Lendcr's Namc
� z C.cnder's Address
V 0 I certify d+at 1 have resd this application and siatc U+at thc abow infwmatiun is
w F cortcct I agece w comply wiih all city and counry onfinances and suie laws relaring w
0 U building conswction, and haeby wthori�t ccprcsenutivcs of �his city to cnlcr upon �trc
W ahovc-mcnuoned property for inspec�ion purposes
� a (Wc) agree to save, indcmnify and keep hazm�ess ihe Ciry of Cupertino against
� Iiabiiiva,judgmcnLS, casLt and expenses which may in any way acccuc aBainst said City
V z in consequence oC th 8ng of this permiG Date
� APPLIC ANDS WILL COMPLY WiTH ALL NON-PO1NT Issued b:✓:
SOUR R LA
� t � Re-roof:
Signaturo licant/Contracto �� T of Etoof
w4zaxoous Ma�tnc.s oisc�.osu� YPe
Wi111he applicant or fuwrc building acupant storc at handlc ha•rardous ma�crial
dcfincd by the Cupertino Municipal Codc. Chaplcr 9.12, and U�e HcalU� and Safety
a�, Scction 25532(a)T All roof, � shall be inspected prior to any roofing material being installed.
O Y� °
If a roof is installed without first obtaining an inspection, I agree to remove
Will �hc applicam or ture building accupant usc cquipmcnt or Jcvices which
emi� ha air conuminanu as dcfincd by the BaY Ares Air Qos�hY Managcmcn� all new ; naterials for inspection.
o�s�;���
❑ Y� �°
1 havc rcad the hvacdous maicrials requiromenls undcr Chap�cr 6.95 of ihc CaliCor- �/
nia Hcalth & SafctyCodc, Sectians Z5505, 25533 arx125534.1 undcrstand that iC thc buildinb �
docs "n havc a ten it is my responsibiliry m naify ihc occupant n( �he Da
rcq � cn�s �cn m ei prior m iuuancc ot a Ccnifica�c of occu �r. S ignatui e of Applican __._
� f� All roof coverings to be Class "B" or better
Owncr or authori�cd agcnl �
CITY OF CUPERTINO
6 ITEMS OF 18 PERMI" RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Bl.c: Lot:
APN ......... 31�i40001.00
DATE ISSUED.. 11�13/2007
RECEIPT #.........: BS)00003227
REFERENCE ID # ...: 07L10075
SITE ADDRESS .....: 11)11 NORTHSKY SQ
SUBDIVISION .......
CITY .............. CUPERTINO
IMPACT AREA .......
OWNER ............: NAVCY HOLSWORTH
ADDRESS ........... 11�11 NORTHSKY SQ
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-0540
RECEIVED FROM ....: ATLAS-TRILLO
CONTRACTOR .......: TRILLO, STEVE LIC # 4269
COMPANY ..........: ATLAS-TRILLO HVAC
ADDRESS ... .......: 1965 KYLE PARK CT
CITY/STATE/ZIP ...: SA[� JOSE, CA 95125
TELEPHONE ........: (408)286
FEE ID UNIT QUANTITY AMOUNT 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 2,000.00 0.50 0.00 0.50 0.00
EPERMITFEE FLAT R.ATE 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 AMOUNI' REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 516.12 #9086
---------------
TOTAL RECEIPT : 516.12
VOICE ID DESCRIPTION • VOICE ID DESCRIPTION
-------- ---------------------------- -------- -----------
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL
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CITY OF CUPERTINO
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,�uPE�T�i�o PERMIT APPLTCATION FORM
APN # � '� Date: ,
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Building Address� ��� `
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Owner's Name: � Phone #:
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� � c�� License #:
� Contractor: I hone.
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Contact: Phone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ l'lumb ❑ Mech ❑
Job Description:
Residential Commercial ❑
For Residential stallations:
Attic � 1 St floor 2 floor �
�dhere to min set back requirement
r'or Commercial Installations:
Replacement same weight ❑ Additional weight (s�:ructural calcs) �
Structural Calculations required for new installation �
New installation Planning Ap roval Required ❑
Cost of Project: �� \ Type of Constru�tion: Occupancy group:
�Uu
Strapped ❑ On Platform ❑ Bonded Cl Sq.Ft. Floor Area:
New Location � Replacement �
Qty. if Fee Description Fee Group
Applicable Fee ID
BENERGY F;nergy BUILDING
BREMFURN F'urnace MECHANICAL
BREMACOVER f�/C Unit > 10,000 cfin MECHANICAL
BREMAIRHAN ��/C Units <= 10, 000 cfin MECHANICAL
BREMRECEPT ]Zecptl, Switch & Outlets ELECTRICAL
BSEISMICRE ;�eismic Fee Res BUILDING
BSEISMICOM ;�eismic Commercial BUILIDNG
EPERMITFEE :�lec Permit Issuance ELECTRICAL
MPERMITFEE ]�Iech Permit Issuance MECHANICAL
PPERMTTFEE l'lumbing Permit Issue PLUMBING
BPERMFEE :31dg Pernut Fees BUILDING
BPLANCHK :'lan Check Fee BUILDING
BPGAS Jas Piping System Fee PLUMBING
BUSLIC Business License BUILDING