06030014 F222043
TY OF CUPERTINO ' yrt+�� .c < ,�vmlr sew•'+. - 1' .
emt-D1nc Drv1s1oN PERMI"I' C,�N.�%T,'� OMTION =-
DING ADDRESS: PERMR No.06030014
BARLEY CTER'S NAME: PERMR 1$UE DATE
FEELEY BARRY J AND NORMA R TRU 03/03/2006
SANITARY N0, CONTROL NO.
ARCNITECT/ENGINEEA: BUILDING P 1171NEO
BLDG ELECT PLUMB MFLTf
up� LICENSED CONfRACTUR'S DECLARATION Job Description
rd 1 bacby.farm Wt 1 mn li¢nmH under p,o. m iboof Clupcs 9(commencing P
Nth Sstkm700Wcf ob3ofdc Budrow fen"vu Code.admylienc4
-
into REPLACE FURNAeE- AND ADtC
;fix 1.ittvc Cl.w - .S Co... 5 aa _ -
�a •Cmuacee
q W ARCH( be pud
DECLARATION
e 77 1 undmtund ns
my p4 .+✓til]be urW u ic reearN
li!
10 IJuonedPm(cuiovl V4t� 1lfUb
OWNER-BUILDER DECLARATION
i 5 1 hereby tiff.Wet Icon crowµfru.the Cr.ore e Lkrne Ir'f«We
O rollmvin(reason.(Section 7031.5,Bud.and Pmrdhw Code:My city or comxy
g Mich m vire a permit to e«wrun,.Ice,improve,de.olid,or rtpair any $5703
pd.to iu sn ....lm mldma Wcapµiem r«wch pmmitto Rk.dytd m t
< thatro uliccncd pvraumm We pmvicou aWe C«vrewilienw lesw(Chaµu9 Sq. Ft.F bdi&7Ar'ba g. Valuation
E S (rn.memin(rid Seat..7")4 Di .o 3 M Oc Bndna and P.ralmm Code)« tl
_
Out be u ergoµ b^refroe ma We bwu for the d ftd eaatpil .My s'lolulm a
Section 7031.5 by mr,appliesmt for a permit mbjeu the app4ont to•civil pemlty of r Occupancy Type
cot mac Wan nK hmdmi dplW(1300}
O I,M w of We propery,«try employee with w.Ra u dcv wk eo.pewadrn,
will m dw work.and mrucllvC 4 not inveded or offered f«tok(S 7044,Budw Required Inspections
and Pmrralons Codc:71c CO. 1 I k UW d«es nest apply u m rwocr a q Pe
pmPNtr wfio roilm«impmKu thmmo,ad wro aou.ah woes hiiowu«wmgn h4
owe unpby«es,µvWdcd Thu a«hvnprmemenu ue cot intrsdd«aBcmd f«axle.lf.
bower,
WTitin will eutw Oc burden of eµmoevninteisWead edlct roarcI build«or 4innp.p c Ter the wtn- "
purpose of
uk).
❑1.0 pone a the pe"ert,me ue Wu y eonuuting with ILased wnh.u«am
c.nur«a thµDices(See.T04d,B,.tn...and Pwfeodme Code:)The Comrr s li-
enr lesw tion a«.PPIY ro m ower a propvtr.vho IuiM.«hnprmn d,veon,end,
wro conv.cla f«veckµmjew told•cwuau«(e)0enwa p«w.nt m iEe Conrnore
Lk w .
❑lam nemµurttle See .Bh PCfor bot taw
c Due
WORKERS COMPENSATION OECI.mRATON
1 bueby dBren under p®tIy of pc jury ore of We foilowint Erelarulmw
1-�-k
Il u. endMl.dnuinsC«=mofCo llowlr.Wuref«Wort .Compen-
on,u pwvlded fur by Section 3780 of We lesbor Code.f«Itr perp.a We for w jch On permit u1 Nw and will noin"W.Ioe.Compeum on Imu .u rcydmd by Section
r1 a We lesbm Coo,f«the perfotome,of the work f«Mich W4 pom4 4 Lu'c
Worker.Cem m Innumee DriermrdPW¢y bermrtier. PON Nu.:
�—�- CERTIFl OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section nod n«hec«npleub BWe permh 4 for.EuntrrGdol4n($10(1)
«oto)
1 certify West In the crfurmaoe a We w«k for which 04 permit a hoed,I andl not
cmpioy my Peron in my ma«cr w u to become wbpa to the WakenCmnpcoullmi
Ues .ac,,Hfomiu Doc
AppBod
NOTICE TO APPLICANT:If,a[w on king Wu Cenirlu¢Or Exemption,you shouts
become wbjm W do Wr 'e Compenwtlon p W«u a the lesb«Code,you mun
.JO fonOwith w.ply with wch pwviuou«Wu pemlt ehdl be danrL oe k
z ^' CONMUCIDON LENDING AGENCY
'e.4 1 meby dorm ace there I..ton .keding atone,for do pefwnmcc or
!Yi> dm work for whkh thu permit 4 Wood(S¢3091.Ci,C.)
Qtcrdds Name
z Ladcrs Adcrew
U O I certify Nat l Imre mad W4.ppliction W enc Wu the abme wo en W w 4
U.F^ cpttet 1.(rt<In comply with d1 city aM county orditm oee ad scow 4wa rtluing w
0U .M .rocnuooed property f«rivpecuby �ron Wpneez, esof Olt city.cucr upon tM
I]r,a. (Wc)acne to tote.Wernolfy moa keep hmmkw Ile,City or Cupertino aS.indt
i-.cn 14blihim Jud:.W cow W mpenm Mich..y 4 mor why wane aiaiul told City GG
U 4
in APFLII Ane HDERST'AN aWNO WILL CO PLY WITH ALU,NON-POINT Issued by: Date
0 R G TIONS.
Re-roofs
f APµt`HAZkRDOUS MATERIALS DISCLOSURE Date Type of Roof
Win theappliam«Adore luildlnc oevWt cow«boodle tuv d ower.]
u dnaad DY We CupeNm MwMWI Codc.Chapter 9.11 ud the He h and W.y
Code.Sedw 21533(.)? f`TV,/ All roofs shall be inspected prior to any roofing material being installed.
C Yu
Wm the.pPlicmi or fwce 1mlldln{camp,.ve cgdpet nt« wbkh If a roof is installed without first obtaining an inspection,]agree to remove
emit haudnu air enumiilmtm u "(Ircd by th Bay Am Air Qedity Mmarmcnt all new materials for inspection. -
INn t7
[]Y. u
I home. dru rot mr.�crla4 rryul..cnmurkrCh.pter6Y5oftheUifor-
nialkalW h Safety Coc c,Section 25505.25533 ad 25334.1 uderrund Wentathc bteldin(
don rolcurte YNtoarnant Wm itu regmd,llly n boor,We nrdc
znm n c cot to rr. 'bear Signature of Applicant Date
or « t «vdm ant Da¢ All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
i Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI,TINO
Building De artment
JOB ADDRESS- PERMIT #
6aX 66 d 300 (y
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
Signature Date .
Please check applicable subcontractors and complete the followinginformation:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating i )
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature ate
CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: bethe
COPY # 2
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35606023.00
DATE ISSUED. . . . . . . : 03/03/2006
RECEIPT #. . . . . . . . . : 33439
REFERENCE ID # . . . : 06030014
SITE ADDRESS . . . . . : 22043 BAXLEY CT
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : FEELEY BARRY J AND NORMA R TRU
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4744
RECEIVED FROM . . . . : A PERFECT CLIMATE
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE . . . . . . . .
:
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW SAL
BREMAIRHAN NO.UNITS 1.00 10.26 0.00 10.26 0.00
BREMFURN NO .UNIT 1.00 14 .31 0.00 14 .31 0.00
BENERGY PERMIT FEE 1.00 34 .86 0.00 34 .86 0.00
BREMRECEPT NO. OUTLETS 1.00 1.20 0.00 1.20 0.00
PPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
BSEISMICRE VALUATION 6, 000.00 0.60 0.00 0 .60 0.00 ,
EPERMITFEE FLAT RATE 1.00 38 .37 0.00 38.37 0.00
MPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
__________ __________ __________ ----------
TOTAL PERMIT 176.34 0.00 176.34 0.00
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ____________ ---_____-_-__-____
CHECK 176.34 024340
TOTAL RECEIPT 176.34
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL