07090047 CITY OF CUPERTINO �T
BUILDING DIVISION PERMIT � � � I ?R �ON, /
BUILD NG ESS: PERMIT NO.
�1IT9 AMULET DR ATLAS-711LL0 HVAC 07090047
OWNER'S NAME: PERMIT ISSUE DATE
GRACE CHEN 1 1965 KY:_JE PARK CT 09/10/2007
JE: SANITARY NO. CONTROL NO.
(408) 281-8931
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p cO LICENSED CONTRACTOR'S DECLARATIONJob Description
U P I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is ADD A/C
t a a in full force and e .
��Z Licen 1 s Lic.N
F Date Contractor
ARCHITECTS DECLARA N
i < l understand my plans shall be used as public records
)qU
'u.l- Licensed Professional
OWNER-BUILDER DECLARATION
> I hereby affirm that 1 am exempt from the Contractor's License Law for the
3
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
,0,ff which requires a permit to construct,alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
2 I-� (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 4
000
'352 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 Number Occupancy Type
not more than five hundred dollars(5500). 3264301 3
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Conuactries License Law does not apply to an owner of (1 p
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Lit-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
❑I am exempt under Sec. B&P C for this reason
Owner Dare
WORKER'S COMPENSATION DEED RATION
I hereby affirm under penalty of perjury one of the following declarations
I J sae and will maintain a Certificate of Consent to self-insure for Workers Cmnpen-
on,as provided for by Section 3700 of the Labor Code,for the performance of the
fork for which this permit is issued.
ave and will maintain Workers Compensation Insurance,as required by Section
of the Labor Code,for the performance of the work for which this permit is issued
Workers Compensadop Insurance c 'er and Policy number are:
Carrier. Policy No.:
CER I• ATE OF EXE34PTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is far one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
0 forthwith comply with such provisions or this permit shall be deemed revoked.
z" CONSTRUCTION LENDING AGENCY
[~i CA I hereby affirm that there is a construction lending agency for the performance of
(Y.✓ the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lenders Name
a+ Lenders Address
U 0 1 certify that I have read this application and state that the above information is
LL ►' correct.I agree to comply with all city and county ordinances and state laws relating to
,rJ U building construction,and hereby authorize representatives of this city to enter upon the
a above-mentioned properly for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments,costs and expenses which may in any way accrue against said City
U z in consequence of c granting of this permit.
APPLICANT ERSTANDS AN WILL COMPLY WITH ALL NON-POINT Issued by:9Date
SOURCE R TIOjYS:""
Re-roofs
Signature of App ontrac _.---- Datc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs ;hall be inspected prior to any roofing material being installed.
C3 Yes ❑No
If a roof i;installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
Cl Yes O Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hcal afely Codc,Sat' 25505,25533 and 75534.1 understand that if the building C -
docQ A2
s c d have a n4 that it is my responsibility to notify lh0 occupant of the
Me re en mel prior to issuance ofa Ccrufl, to guru, er. Signature of Applicant Da e
(�JAll roof coverings to be Class"B"or better
Owner or authorized agent 11 Dare
CITY OF C UPERTINO 0✓7 0 ? 00 V'7
CUPEkTINO PERMIT APPLICATION FORM
N # Date:off
I [2 Z�l
Buildin Address:
/= ) -5 1
A y--
Owner's Name: Phone
: _
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or Phone_ ��iCL11SC :
T,� V/ 4? �� (�
Cupertino Business License
Contact: Phone: <-
#:
Building Permit Info:
Bldg ❑ Elects P:umber Mec1-i—C�
Job Description: ^^j
- Alc
ResidentialV Commercial ❑
For Residential Installations:
Attic ❑ I5t floor ❑ 2nd floor❑
Adhere to min set back requiremen
For Commercial Installations:
,placement same weight ❑ Additional weight(strictural calcs) ❑
,structural Calculations required for new installation El
New installation Planning Approval Required ❑
Cost of Project Type of Construction: Occupancy group:
V
Strapped ❑ Oh Platform EJ Bonded t Sq.Ft. Floor Area:
New Location Er— Replacement
Qty. if
Applicab e Fee ID Fee Description Fee Group
BENERGY En-,rgy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/,'-Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/,'-Units<= 10, 000 cfin MECHANICAL
BREMRECEPT Recptl, Switch & Outlets ELECTRICAL
BSEISMICRE Se.smic Fee Res BUILDING
BSEISMICOM Se.smic Commercial BUILIDNG
EPERMITFEE Elf>c Permit Issuance ELECTRICAL
MPERMITFEE Wch Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BPGAS Gzs Piping System Fee PLUMBING
BUSLIC Business License BUILDING
CITY OF CUPERTINO
7 ITEMS OF 20 PERMIr7 RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blh: Lot:
APN . . . . . . . . . 32643018. 00
DATE ISSUED. . . . . . . : 09/10/2007
RECEIPT #. . . . . . . . . : BS000002600
REFERENCE ID # . . . : 07090047
SITE ADDRESS . . . . . : 21:376 AMULET DR
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . . GRACE CHEN
ADDRESS . . . . . . . . . . : 21:376 AMULET DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1301
RECEIVED FROM . . . . : AThAS-TRILLO
CONTRACTOR . . . . . . . : TRILLO, STEVE LIC # 4269
COMPANY . . . . . . . . . . : AT: AS-TRILLO HVAC
ADDRESS . . . . . . . . . . : 1965 KYLE PARK CT
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408) 286-8931
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
BREMAIRHAN NO.UNITS 1. 00 10.26 0. 00 10.26 0. 00
BREMRECEPT NO. OUTLETS 1. 00 1.20 0. 00 1 .20 0. 00
BSEISMICRE VALUATION 4, 000. 00 0.50 0. 00 0 .50 0. 00
EPERMITFEE FLAT RATE 1. 00 40.79 0. 00 40 .79 0. 00
MPERMITFEE FLAT RATE 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 169 .19 0. 00 169 .19 0. 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL 508 FINAL MECHANICAL
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
'"UPEkTINO
Buildirn De artment
JOB ADDRESS: PERMIT #
U C?00-�/
OWNER'S NAME: GLS- A C PHONE # 7 - 3/-)-f
GENERAL CONTRACTOR: FAX #
-7�1 "17116 z
I am not using any subcontractors: �i
Date
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
Til
_ //,v zr
e ontractor Signature Date