04010002 CITY OF CUPERTINO z.;4:gg:r
1
BUILDING DIVISION PI✓RMIT CONTRACT.nR INFORMATION
But ILDING ADDRESS: AAA FURNACE & AIR CONDITIO Tt1�°04010002
OWNER'S NAME: PERMIT ISSUE DATE
PRICE TRUST
ONE: SANITARY N0. CONTROL NO.
(408) 293-4717
ARCHITECrIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u o o LICENSED CONTRACTOR'S DECLARATION
W
C 1 hereby affirm that I am licensed under provisions of Chapin 9(commencing Job Description
tJ with Section? M)) I Division 3 of the Rusin. nd Prufcvvions Code.and my license is p,p Al
Inmatprrdama fee - II REPLACE FURNACE & ADD A/ IV 16w-- ®
,lliZ Liee., L L'.a V
��p D CuntranOr
Uej ARCHIlOn..it OVAT FEB 0 g 2004
1 understand my plans shall M used u.pdRlie records
u.t, Licensed Pmfessinnal
!`v, OWNER-BUILDER DECLARATION q
q<S I hereby alirm that 1 am accept form the Contractors Licen=Low for the BUILDING
■'��
p 0 following reason.(Sardun 7031.5.Business and professionalprofessionalCode:Any city or county
K m E which=quire a Permit to construct,eller,improve.demolish,or repair any Smi
.2y poor to its issumcc.also requires the applicant for such Permit mf lc a signed statement
< that he is licausad pursuant to the provisions of the Contractor's License Law(Charter 9 Sq. Ft. Floor Area Valuation
yFp (commencing with Section7W0)of Di vision 3 of the Real ones and Profcssiums Coda)or
i
that he is cmmpl therefrom and the basis for Ne alleged exemption.Any violation of
Section 1031.5 by any applicant for a penin mbjccu the applicant to a civil Penally of 3 2RN802iber 0 0 Occupancy Type
more ore Iran Eve hundred dollars(550)). P Y YP
1,u owner of the r mpeny,Of my employees with wages as their sole compensation,
will do the work,and she stud==is not intended or offend for sale(Scc.1064.Business
and Professions Coic:The Contractor's Liceme Law does not apply to an owner of Required Inspections
property whu builds m improves thenen,and who does such work himself or through his
own employees,provided that such improvements arc not intended or offered for sale.If,
however,Ne building or improvement is sold within am yeas of completion,Ne owner.
Wilder will has the burden of proving that o did nor build or improve for propom of
sale.).
0 1,as owner of the property,am exclusively contracting wit licensed convectors to
construct the project(Sec.1044,Business and Profusions Code:)The Convocmr's Li. _
ease Law does not apply in an owner of property who Wilds of improves themon,and
who contracts for such projects with a eontr==r(s)licensed pursuant to to Contractors
License Law.
❑I am emmpt under See. B&P C for his mason
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby offmn under penalty of perjury one Of the following declarations:
I have and will maintain a Ccnifcma of Consent o self--insure for Workers Compen-
7037(fir
ion.as provided for by Section 37W of doe labor Cods,for the performance of the
ank for which this permit is issued.
1 ban and will maintain Worker's Compensation Insurance,u sequined by Section
of the labor Code.for the performance of the work for which this Permit is issued.
y Worker's pensation luuuntt carrier andPgolicy orart:ore I`0NRR�� CERTI'i A FEXEMPf1ON FROMW RK R '
COMPENSATION INSURANCE
(Thu section need not o complied irthc Permit is for Onc hundred dollars(SHMB
less.)
1 sanity that in the perfunnance of the work for which this permit is issmd.I shall nm
employ any person in any manner an M m became subject to the Workcn Compcmation
Laws M Caliromia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenifcam Of Exemption,you should
Wcome subject to the worker's Compcuation previsions of the la Wr Cndc,you must
0 z forthwith comply with such provisions or this perms,shall he formed invoked.
z O CONSTRUCTION LENDING AGENCY
(. I oreby aTom Nal tore is construction knding agcmy for the performance of
a
she work for which this permit is issued(Sec.3091,Civ.C.)
!y Q Lefu sName
6, Under's Address
az
U O I vanity Nat I have rad this application and sue that Ne aWve formation is
IL F-' COMCL 1 agree to comply wish all city and county ordinances and state laws relating to
O U Wilding conswction,and hereby authorim represenurivsu of Nis city to enter often the
} W ahwe-mmlirnad prorcrry for im,eedon purposes.
F'
Q. (We)agree to sass,indemnify and kap harmless the City of Cupertino agaiw
N limilllics,judgments.costs and expenses which may in any way accrue against said City
U z in consequence,of the granting of this permit.
.. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dat/, o
SOUR REGULATIONS.
Re-roofs
ver Applin siCrntractoo Da=
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building uccurant score or handle hnaNm
uus amrml
as carload by the Cupenim Municipal Code,Chapter 9.12,and the Health and Safety
Cuda,OYes 25512(x)? Nr All roofs shall be inspected prior to any roofing material being installed.
Will the applicant ore building esu cyuipmcm or d<vim which If a roof is installed without first obtaining an inspection,I agree to remove
it haamdnus air contaminants as dcfncd by Ne,Bay Arca Air Quality Managcmcnt all new materials for inspection.
is is.?
Ycs
Ihavc«adthehma .1.1u,iaismquim=nuun&rChap=r6.950ftheCaliror-
niaHealth&Snfcty Cods Scefuas25505.25533wd25534.lundcmum iflo Wilding
fou mol cuncn0y bean n=:Tool Nat it u my respauihilily m maty occupant of the -
=quiremcnts hichmustbcmnpdunuissuan¢ofaCerdfc p eupency. Signature of Applicant Date
On -.0
Owaumted.e ag t DaiAll roof coverings to be Class "B" or better
CITY OF CUPERTINO
t ; FURNACE/AC" o �z e)/ c)CITY OF
Z
CUPERTINO PERMIT APPLICATION FORM
APN
Building Address:
Owner's Name: Phone it:
1, loe.oc 3 3 - 74-zz Phone: License #:
o C. — - /
Contact: Phone: Cupertino Business License #:
rBldgO
77 _
Building Info:
2
Elect Pl M ch
r'ption:
G v '
Residential Commercial LY
sq/� •3oeaP Iry
For Residential Installations:
Attic ❑ 1't floor ❑ 2"d floor❑
Adhere to min set back
For Commercial Installations:
Replacement same weight— Additional weight (structural calcs) ❑
Structural C ations required for ne installation ❑
New inst ation Plannin Approval R uired ❑
Costo roject: 0� QP ype ofM_C�f
n: Occ ancy group:
;r
Strappe m Li o ed Eta oor Area:
New Location t5� Re laceme
Qty. i&
Appli64le Fee ID Fee Description Fee Group
f BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
CITY OF CUPERTINO
Om 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp: Rng : Sub: Blk: Lot :
APN . . . . . . . . . 32634071 . 00
DATE ISSUED. . . . . . . : 11/12/2003
RECEIPT 4 . . . . . . . . . : 23770
REFERENCE ID # . . 03110062
SITE ADDRESS . . . . . : 10101 N DE ANZA BLVD # 100
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : M7 CORPORATION
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : , CA
RECEIVED FROM . . . . : LAWRENCE VERTIN
CONTRACTOR . . . . . . . : TODD L JACOBS LIC # 24941
COMPANY . . . . . . . . . . : TEAM SERVICES INC
ADDRESS . . . . . . . . . . : 3028 SCOTT BLVD, STE C
CITY/STATE/ZIP . . . : SANTA CLARA, CA 95054
TELEPHONE . . . . . . . . : (408) 982-0373 .
16FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
-- - - - -- - - - - - - - - - - ------- -- - - - ----- ----- - - - - -
- - - ------- - - - -------
BENERGY PERMIT FEE 107 . 00 32 . 10 0 . 00 32 . 10 0 . 00
BPERMFEE VALUATION 5, 000 . 00 107 . 00 0 . 00 107 . 00 0 . 00
BSEISMICOM VALUATION 5, 000 . 00 1 . 05 0 . 00 1 . 05 0 . 00
BPLANCHK PERMIT FEE 107 . 00 90 . 95 0 . 00 90 . 95 0 . 00
-- ------ - - - - - - - ------- - - - -------
TOTAL PERMIT 231 . 10 0 . 00 231 . 10 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
- - - - - - - - - - - - - - -- - - - -- - - - - - --- ----- - ------------
OTHER 231 . 10 AMEX
TOTAL RECEIPT 231 . 10