03120013 CITY OF CUPERTINO ''-
BUILDGNGDIVISION PERMIT iX0NTRAC''TOR5INZ'O.RMA"I;IQN
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BOLDING ADDRESS: A & H HEATING PERMITNo03120013
7512 BOLLINGER RD
R'S NAME: PERMIT ISSUE DATE
P 770 CHESTNUT ST 12/03/2003
PHONE: SANITARY N0, CONTROL NO.
(408) 279-0722
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
lop LICENSED CONTRACTOR'S DECLARATION
1 bemby M.that 1 am licensed under prnvisluns or Chapter 9(commencing Job Description
with recti ]O(Ml)of Division Sof du Huaineas�pgrofessivas Code.end mylicenseb
+ � tohol aadefr / R ���)��ii'' REPLACE FURNACE
Llme Clue Lic.N N �I9 � p p®
Dau 1vCp'�69■ T s�
ARCHITECTS DE A 1 N
I ?undersand my plans shall be used u pre lie rtrnrJa
yt DEC 15 2003
au0 Licensed Professional
OWNER-BUILDER DECLARATION
Z I hereby affirm that 1 am exempt from tW Contractor's License Law for the
00 following memo.(Secliun7031.5,Business and Professions Code:Any City Or county BUILDINGS F! which mqulms o permit m construct.alter,improve,demolish.or rtput,any almcom, N $2355
iy prier to its isauance.alw minim the applicant forsuch pmmiuofilc uigncd sutemcm
gxx< than he is liccnwd pursuant to the provision or the Contractor',License Law(Chapter 9
Sq. Ft. Floor Area Valuation
(commencing with Section]ODO)of Division 3 of the Business and Professions Cude)or
e that he is exempt therefrom and the basis for the alleged exemption.Any violation Of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 V 0 Occupancy Type
not mart than five hundred della.(M).
❑I,....Of0microperty,or reyemployces with wagqu Heir able compensation,
will do the work,end the smucome is not intended or offered for sale(Sec.7041,Business
and Pmrculou Code:The ConmumrS Lim.Law docs Mn apply to an owner of Required Inspections
progeny who builds or improves thereon,and whodoes such work bimulfor through his
own employees,provided that such improvements me not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion.Ne owner.
builder will have the burden of proving Nat W did not Wild or improve for purpose of
.1,1
1,as Owner of the property,am exclusively contracting with Iiceved conuacma to
convect Ne project(Sec.7044,Business and Professions Code:)The Concracmr's Li-
cense Law does not apply to an owner of property who Wilds or improves theme..and,
who contracts for such projects with a contractor(s)licensed pursuam u the COalaeler's
License Law.
❑1 am exempt under Sac. .B h P C for Nis moon
Dau
WORKER'S COMPENSATION DECLARATION
I hereby strum under penalty of perjury aro of the following dmiscon ov:
❑I hers end will maintain a Ccnifmate of Covent mself-Insure for WOrkchCompen-
cation,as provided for by Section 3700 of the ISWr Code.for the performance of the
work for which this Permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Code,for du performance of the work for which this permit Ia Issued.
My Worker's Compewtion Insurance canicr and Policy number am:
Carrier. Polig2:Rdio 10 7r,
CElmFICATEOFEKEMPTION rjtOM WORKERS'
COMPENSATION INS NCE
(nix section need nm W completed Bible Permit is for one hundmddolla s(Still)
or Ica.)
1 gnify that In the performance of the..,it for which Nis Permit is issued.I shalt or
employ any person in any manneru u to become subject in the Workers'Compensation
Laws of California.Dam -
Applicant
NOTICE TO APPLICANT:If.after making this CMIIICAm of Exemption,you should
become cbjecl to IW Worker's Compensation provisions or the Labor CmR.you must
Z forthwith Comply with such provisions or this Permit hall W deemed revoked.
tiO CONSTRUCTION LENDING AGENCY
IWmhy dorm that Inc.ire connmctinn lending agem:y for the performance of
7 the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender.Name
z Lenders Address
J I cortify Nu 1 have end this application and mu than the salve Information is
0 building l agree to comply with all City and county ordinances and Cute avis r upon
m
O W.....c.....—ie and herebysped..poop,menutirss of Nis City totourupon thd
W ahovn(We)agree
to saw,
for lv ni ry an Purposes.
Iles
(We)came to cons indemnify and kith hay in an the y c of Cupertino to ity
Uy incoisquencecnacostsang Ofpcnusmit, may in anywayacme gelut aid City / ?�
C.) APPLICANTCUNDEof the RSTANDSthis AND WILL COMPLY WITH ALL NON-POINT Issued by: Date l
Sg k RI�EGULATIONs. 1 `�
(/a�OA V I Z�L� Re-roofs
Sin c fApplicantiCOntractor Doe Type of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle hagarduus material
dcMed by dm Cupertino Municipal Cock,Chapter 1,11,and Ik Health and Safely
.Section 25532(x)7All roofs shall be inspected prior to any roofing material being installed.
❑Yq
No
will the appbgnt or mtere building..Pont use equipment or deride,which If a roof is installed without first obtaining an inspection,I agree to remove
emit harvdou sir contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Diaulet?
❑Yca
I have mad the hmsnc ms maurlals mquimmems once,Chapter 495 of One Califar. -
.!a Health&SdelyCode.Seedons 355115.35533 and 25534.1 uneemmnd than if lW Wilding
does not Cumndy have a mount,that II 4 my respensibil ity to notify IM Occupant of the
require hicbmust Wmet r icucgora e 'Ecateooccup Signature of Applicant Date
Owndr u,aumnrivcd agent Daa - All roof coverings to be Class"B"or better
CITY OF CUPERTINO
It• 1 Of 1 PERMIT RECEIPT OPERATOR: 9nem
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35924007.00
DATE ISSUED. . . . . . . : 12/03/2003
RECEIPT #. . . . . . . . . : 23947
REFERENCE ID # . . . : 03120013
SITE ADDRESS . . . . . : 7512 BOLLINGER RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : YAP
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4333
RECEIVED FROM . . . . : DALE PHELPS
CONTRACTOR . . . . . . . : PHELPS, DALE LIC # 12079
COMPANY . . . . . . . . . . : A & H HEATING
ADDRESS . . . . . . . . . . : 770 CHESTNUT ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95110
• TELEPHONE . . . . . . . . : (408) 279-0722
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- -- ------ ---------- ----------
BENERGY PERMIT FEE 1.00 23.10 0.00 23.10 � 0.00
BREMFURN NO UNIT 1.00 13.25 0.00 13.25 Li 0.00
MPERMITFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00
BSEISMICRE VALUATION 2,355.00 0.50 0.00 0.50 0.00
---------- - ----- ---------- ----------
TOTAL PERMIT 72.37 0.00 72.37 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
OTHER 72.37 MASTERCARD ,
TOTAL RECEIPT 72.37
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL
CITY OF CUPERTINO
FURNACE /AC
*C FURNACE
PERMIT APPLICATION FORM
APN # .359 - r 007 Date: 2
Building Address: 7Pa aoL L` 4 e p-.0 Rp --
Owner's Name: 1'houc #:
VAP
Contractor: H� IN� G License #
3o r4
Contact: DA Phone #•
/`! G� �g-p�aa__
Applicant/Contractor:
-0 -2
Building Permit Info:
Bldg Elect PlumbMech
Job besat on:
12 ��esidentitial: or
Commercial _
Sq.Ft. Floor Area: $/Sq,,Ft.:
ArchitecL/Engineer: Valuatioi •
JJ �
ypz ofpns�jtct' L Occupancy Group:
Qi c ty. L
A le Fee ID Fee Descri tion Fee Group
B ERGY Ener UILIDNG
EMFURN Relocation of Furnace MECHAN'ICAI
BREMACOVER A/C Unit > 10,000 cfm MECHANICAL
13' AN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILIDNG
EPERMITFEE Elec Permit Issuance h ECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees UILIDNG
BPLANCHK Plan Check Fee BUILDNG
BUSLIC Business License T UILII5NG