06050050 CITY OF CUPERTINOT��hs. � �r
BU9LDINc DIVISION PERNQT �C,O�t.:�. adt"OPRNFMMAT�ON-
BUILDING ADDRESS: A PERFECT CLIMATE PERMIT"x'06050050
6353 BLACKWOOD DR
OWNER'S NAME: PERMIT[SUE DATE
TIM MONDALE 10570 S DEANZA BLVD 05/05/2006
NE: SANITARY NO. CONTROL NO.
(408) , 861-9545
7ARCHI-fECT/1ENCINEER: BUILDING PERMIT INFO
BIRO E1FLT PLUMB MECH
LICENSED CONTRACTORS DECLARATION Job De cn hon, t,r�t1 hereby affirm thn 1 ma Itr�under proriaiatu a Copsrr 9pS 7O,TBIaDMaianlofNCBuvnraWRafcscaru dc.and my lane isy�.a # anraaAa o REPLACEMENT OF FURNACE a < '4ys
�qzq Llame IJc./I .
ARCHrTECTS An _-- I , 2006
PggP��77 I undenuml mY PUna a1W I le aW u public rtc«da
)yW
ALL Ironed PmrnssbnJ
G OWNER-BUILIIER DECLARATION .-ate (' R f
i I hereby a im ron that 1 acaemp ft«a due CWOVs Li¢nx lav for thc ,f V �,a ri('
3O
fn .g..(Scctlan 7031 S.B¢ o W Roruti mC«u:Any city in—Y ✓ (] 927
<$ whuh U.a pump m�alt=,nnprc a domahh,or mpair an,aocwR
i y poor W ns int...aBu tryuhes 1M applicant for soh permit to rho•upord sutemcm
that M is licenscd p..'to thc Wm WOOS d the C--"Manx Law(Chyv9 Sq. FI. Floor Area Valuation
FFG (eomntetrLt{with Seen.7000)of Division Scar the Buainns and Pmf®au C.&)or
$ Nn be b ecmp acidiom and the huh r«the a[WA eamptim Any nutation d
Sc ion7ml5 by any aPpoam for a permh"-hjca AFN Ntiftluer Occupancy Type
o«tome ton five hmdred dawn WOn
❑L n otvo=of the poputy,or ray unployun wbh wagu an Nch sac mmpenadon.
wN W the wortand me mo=re h non io,Oa naafrued for nm(Sec.7014,Bum. Required Inspections
oro Professions uadalf L.
Code:the Coolame a«
e Law doapply m an owner a q p
property who hWW«improves thereon,and who dou s«h wort hianocff WWrooth bh
awm M00yai,pov Nn4x2 noptvemenu art oat nnnndcd or oRnydfor> 14
however.coc bNWing or hprc mrnt 4 soldw inoneyewofcompkdm.theowrcs-
builder w10 have me b,u0m of proviat On,M did txt SWM«improve r«potpore of
air_}
1.n owner of On pop=ty.am—1-ively contracting with 6mncd tmoucmra b
c«uooct the p,ajea(Sc 7 .Btmnes aN Profcssiw Code)1h<Cmoa=n(a L,
anon taw oma on apply On an owner a popery wEa poilds m imp.Noone.a cl.
who cmuacu In,such pon ccv,with a amacnrW flamed p«aau n the Convaaah -
Lkena, aw.
❑lam......pa muter Are .B&PC I.Olt moa
Own r Dam
' WOItKF]t5 COMPENSATION DECLARATION
1 hereby affirm t P=hy of ptoyo y coo of the rallo tial declasWioru:
Won,
and wlll for by C=ti 3700 d Conemb xlr-inmrcf«lVdrkcfaC of
scion,n bicb tN for by Scotian 1T00 d th labor Coda for the p=fomana of to
work f«whuh uta p=mh is unaetL
❑1 have and will main ion Vlo .Compmation Inmrata.n mtpdred by ScNm
7700 a tho labor Cade,for de perfortnmme¢the wort for which this perms u i—wd '
My W s mP coli Lrmn,ta Artie+aM Policy nwnhe i�"� O
Cartier Policy No: s
CE OF EXEMPTION FRO OMS
COMPENSATION INSURANCE a
(Tait mfr•rcW.1no c«npkml if the pmh is f«me bvWmd do0ae(1100)
mica.)
1 0 oily that in the perr«ma¢c of We wart for which thh p=rofit is roiled.I shall oat
cmplay anypermn in air manner m nmb=mc ablmmto Warton' ��+^
,
Ap,l
laws of California_Dam
NOTICE TO APPLICANT:ff.a(xr making OU Ccnirtcae of Eacmpion.you shauW
hsome aublm y rte Wacta pr Comp.OiJ cmOiL atI a to labor Code yon tow
.JO foMwith amply whh such prw'ul«u«thh permitslWl to dtrnmo rtvokea.
Z CONSMUCT10N LENDING AGENCY
[r 4 1 hcmLy afi,m tot Nee U a mnswcdon lendup apcncy fm the psformuta a
FC > to work for rhuh thv pemtn h issuer(Sc 7097.Cm.C.)
uta Q LetWeYi Name
7 a2 LrndeM1 Add=
U O 1 notify tot 1 havo read On applic and nuc tau Nc above Nfomadm is
corm.1 acme m c«aply with ill city and county Drdi a and sum laws m Wlnr to
p buildlnp ndcncdtian,uW MmrVcu icrirurp cs_ udlcaaw,city mcomr upon th
.r4 aMlc (Wc)a&d Pto gavc farirnpaom lu Oph
(W'ju agrte m ave.andcm W a red heep harmless the coy ro Cupnim¢punt
U N BWBitie,ladp cif Uro ocsud e, "p•whicb may In my wayamoc aIaFnv aid City
U z in AP CA A+ar NEIISTA p 5_i D Wil
AP CA tU)tN�E7RSfANtD�AND W�COMPLY WITH ALL
N N- IM Issued by: Daze
Y SCf`Y T� KxL,S Re-roofs
Si un o AppluD Dan,I
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will On applicant or ftrtsac duloing aaupw start«handle ww
u defined by ftCup= w MaNcipal Code,Chep=9.12 and Ne H tb ami Safety
cam.cation 255320)7 � / All roofs shall be inspected prior to any roofing material being installed.
❑Ym
Will Ne applbant or rw.builNnp occupant.eyulpacnt or define w den If a roof is installed without first obtaining an inspection,I agree to remove
ems hvudvus air eonumi..u defined by the Bay Am Air Omlity Mmap int all new materials for inspection.
Dismal
❑Yca
1 have read Ne haaNws mutuals nou rastondoChaper195odecalir«-
nia HeINh Safny Cade,Sag os 25Sm.25533 v,d 75531.1 urd cnaod Neuf the Witting
d.ren cff�:PF
oe•¢tine that it h my msy«W bility to notify the omlpm or Nc
K. mnaa.ccrrtaneor Signature of Applicant Date
o All roof coverings to be Class"B"or better
Dam
Community Development
C5014Torre Avenue
Telephone
CA 9 014
Telephone(408)777-3228
OF Fax(408) 777-3333
SUPERTINO
Building Department
JOB ADDRESS: (� PERMIT #`
o 15
OWNER'S NAME:-77w� o e PHONE # '—
GENERAL CONTRACTOR: u L FAX #
I am not using any subcontractors:
Signature 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
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
•em 3 of 3 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . . 36918001 . 00
DATE ISSUED. . . . . . . : 05/05/2006
RECEIPT # . . . . . . . . . : 34270
REFERENCE ID # . . . 06050050
SITE ADDRESS . . . . . : 6353 BLACKWOOD DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : TIM MONDALE
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : A PERFECT CLIMATE
CONTRACTOR . . . . . . . : SMITH, BYRON E LIC # 21144
COMPANY . . . . . . . . . . : A PERFECT CLIMATE
ADDRESS . . . . . . . . . . : 10570 S DEANZA BLVD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . . : (408) 861-9545
•FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
- --------- ------------- -- - ---------- ---------- - - -- ----------
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
BSEISMICRE VALUATION 2 , 927 . 00 0 . 50 0 . 00 0 . 50 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 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 164 . 78 0 . 00 164 . 78 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
------- --- ---- --- ------------ ------------------
CHECK 505 .40 024663
TOTAL RECEIPT 505 . 40
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
------------
304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY
505 FINAL ELECTRICAL
CITY OF CUPERTINO
MCI FURNACE/AC
WUPEkTINO PERMIT APPLICATION FORM / /
APN # 3 q l 10 —W
Building
Building Address:
353 13lackwa� t�
Owner's Name Phone
Contr or: , Phone: License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect Plumb E�' Mech Ltd'
Job scrip . n:
Ci
VVI c rk-q o 2
Residential Commercial ❑
For Residential Ins ations:
Attic ❑ I'` floor 2"d floor❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning �A2proval Required
Cost 7�r j let, ✓ Type o onstruction: Occupancy cup.
Strapped d On Platform El Bonded Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
A licab]e Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREN¢URN 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
BPGAS ' Gas Pi in S stem Fee PLUMBING
BUSLIC Business License I BUILDING