08100157 CITY OF�CUPERTINO t aagpC
BUILDII ISION PERMIT CONTRACT(TR INk'URMATTON
�l4Eh�Y4R "v' z0 '?..
BUILDING ADDRESS: PERMIT N0.
10933 LEAVESLEY PL VALLEY HEATING
OWNER'S NAME: PERMIT ISSUE DAIS
ONE:
AMtAllYWO.- CONTROL NO.
(408) 294-6290
ARCHMIC(ENGINEER: BURRING PERMIT INFO
-^" BLDG ELECT FAIMB MECH
u O a LICENSED CONTRACT'OR'S DECLARATION
1 hereby a1Bm thu I we licensed under provisions of Chapin 9(commencing Job Description
With section 7")Or Divimm J of the Business and Prefevsions Cade.an licemsc is
9H inmllraaeamar a >f[( REPLACE FURNACE
�? Uccnsc Cl.s _ Lk.N
—q Date GonlrworIlRILL
7W A HfIECI'S DELLA TION
I undemand my plans shall be used as public records
pyU
t LLo in Licensed Professional
3 OWNER-
BUILDER DECLARATION
1 hereby afrom Nat 1 we exempt from the Contoome's License Law far Uta
a O following ressna(Section 7
0713,Business and Pmfessiau Cade:My city or county
5$ which requlm a permit to construct.alter,hnpmw,demmiWc or repair any su mum
—.ty prier an its issuance,Are requires the applicant retouch pcmdi to rile a signed sudemcnt
E that M u licensed pumunl to Use pre iwmuaf the Contmmars Liecnse Law(chapter 9 Sq.Ft.Floor Area Valuation
y�S (commencing with Section 7000)of Division 3 of the Business and Profesiou Code)m
— that W la exempt therefrom and tin buts for the dlcged exempdon.Any vimisdan of $3699
Section 7011.5 by my appllunt fora permit mbjrcu the appBcant m a civil pwlty of APN Number Occupancy pry'
tat roam Nae fiw hundred dollars(5500enc). P y L]Pe
I.aawm ser Ne ywpay gex x 35615028 . 00
❑ themme,orm 1 sex w(thw uNa(Sec.eom radon,
and dotbeworlc andthrmuaureramm's License
does set spry
to an Busies
dna Pmrawau cane The Conuacm/a Limo Vw ren dot apply lf rd awns is Required Inspections
pommy who builds or ed that
thereon,and who swdoessuch
not in work cr aelfor Nrorgh lou
awe employees,t.umbuilding
Nat such ire Is semw t art not eandnd uroRertd for ale B,
b deter the rmthe arimprovement4sold withinore yearorborrow,frthe oweu-
builder will haw the brrdco of proving that k did rot ddb m improve far purpose of
❑1.u owner of the progeny w u¢Iuvwly eon olmmg with BRnxd mmactms to '
construct the project(Sec.7006.Business and Professions Cade:)The Coorsmafs U.
cove law does not apply an an owner of property who builds or improves Neeson,and
who mntncts foomeh mojecta wiN.comm.mp)licensed puraam to the Cornerstones .
License Law.
❑Iamementa coder See ,BBPCforthiareaon
Owrar (useWORKERS COMPENSATIONDEC RATION
I hrmby 4nna under pointy of perjury arc or the fallowing trsWatiarts
1 ham and will maintain aCeniricea of Conant to self-inmre per Wands Cmmpcn-
be,as provideA for by Secdon 3700 of the I-bor Code.for the performance of the
wort for which this permit in issued.
Maf]Mw and will mainWn Workeh Compensation Insurance,u entailed by Scedon
]OO Ne Mbar Code.per to pafarmance of the work for which Nu permit is ivued. '
My Wo mpeaaaan 1 arae cart(.and Polity her
carried policy Na: ISL/-LT
F fTE OF E%EMFION FROM WORKERS
COMPENSATION INSURANCE
CITE woman need not he compku:d'dthe permit is rorone hundred dollen(5100)
or lexs)
1 cortify,that in the performance of the work roe which Nis pe.I,Is issued,I shall not
employ any person in any marmeto as to become subject a the WaM1eW Camprmatiml
Laws of Califomia Due
Applicant
NOTICE TO APPLICAN.If,afar making this Ccrtifcate of Exemption,you should
become mbjem to the workees CmnRnauon provisions of the Labor Codc,you most
O forthwith comply with such pmvisiou or Nu permit dull be deemed maknd.
z` CONSTRUCTION LENDING AGENCY
[--t I herebym
alum that dart is a corumbut lending agency for the performance of
!ri the work for which Nu permit U issued(Sec.3097.Ci,C.)
AIs nice,Name
Lcedefs Address
U Q 1 certify that 1 Mw read this application uW sea Nu to abow information is '
0, correct,I agree to comply with all city and county ordinances and awe laws relating to
� bribing consuuu(on,and herebyauthorim mpresenutws of this city to enm upon the
W Avw-mendonW progeny for inspeuian purposes.
(WO)agree to new,indemnify and keep harmless the City of Cupertino against
r4jJ liabilities judgments.toss and expenums which may in any'w'ay acerae against said City
V Z in consequence of the gnnung or this permit.
�••� APPLICANT UNDT D D MPLY W NON-POINT Issued by: Date -1ti-oz.-
SOURCERE16 C f.
Re-roofs
Sign urcApp'
}a ommOur ata
/ AZARDOUS MATERIALS DISCLOSURE Type of Roof
AO
ll UE Ilca t or future building oavpant none or haMk haurdous mammal
by q e Cupertino Mound Code.Chapar 9.11,and the Hca1N and Safety
io�25sdz(a)+ All roofs shall be ins ected nor to an roofin material beim installed.
Ya Na P P Y g g
Will the applicant or Tutu ildiog Occupant use equipment or dcvim which If a roof is installed without first obtaining an inspection,I agree to remove
It hvArdons air canuminsnu a Emb1 by Ne Bay AomAlf Qwlty Manegcmc t all new materials for inspection.
h c0
❑ycs u
thaw readthehva ma alarequim=nuum rChapar6.95oftm Califon
does.."tot,
."tot,dyy Cade.S cdau]S NB,Imy uW25556.1 Wemily tIM itchbuilding
Jm rot cuwontY h9v an4 two it u my mpomibility a roufy the occupant Of the
"buiamen� _ Ix onto iswa c cutin a m s Slgn r% pli cot Date
owners am ascm Dam
All roof coverings to be Class'W'or better
CITY OF CUPERTINO
• 6 ITEMS OF 6 - PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35615028 . 00
DATE ISSUED. . . . . . . : 10/24/2008
RECEIPT # . . . . . . . . . : BS000006456-
REFERENCE ID # . . . : 08100157
SITE ADDRESS . . . . . : 10933 LEAVESLEY PL
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : SUSAN MILLAR
ADDRESS . . . . . . . . . . : 10933 LEAVESLEY PL
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4747
RECEIVED FROM . . . . : VALLEY HEATING & CO
CONTRACTOR . . . . . . . : ATKINSON, THOMAS LIC # 141
COMPANY . . . . . . . . . . : VALLEY HEATING & COOLING
ADDRESS . . . . . . . . . . : 1171 N 4 TH ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95112
TELEPHONE . . . . . . . . : (408) 294-6290
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- - --- ---------- ----------
1BSEISMICR VALUATION 3 , 699 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1MFR=<100 UNITS 1 . 00 122 . 38 0 . 00 122 . 38 0 . 00
1MPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1PPERMITFE FLAT RATE 1. 00 40 . 79 0 . 00 40 . 79 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 286 . 04 0 . 00 286 . 04 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
--------------- -------- -----
CHECK 286. 04 #18373
---------------
TOTAL RECEIPT 286. 04
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ------------------ -- -------- ----------- -----------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
•
CITY OF CUPERTINO
FURNACE/AC
CUPERTINO PERMIT APPLICATION FORM
APN#2� / O I U 0 Date: /
Building Address:
Owner's Name: Phone #:
� as3 - ��jLz3
Contractor: Phone#:
Fax #:
Contractor 4ense#: v Cupertino Business License#:
�S�S c7 "74/
Contact: c �n Phone#: Z615
Fax #:
Building Permit Info:
• Elect Plumb [� Mech [�
Residential Commercial El
Job Description:
For Residential Installations:
Attic ❑ 1floor ❑ 2 a floor ❑
Adhere to minimum setback requirement
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural talcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction (Usage Class):
gg \�/D
Strappbd On Platform ❑ Bonded ❑ New Location ❑ Replacement
Valuation:
• Green Building: Must attach Green Building Check list to this application