05100204 CITY OF CUPERTINO h" �'- �
BUILDING DIVISION PERMIT CONTRACTQR INk'0RMATI0IV
BUILDING ADDRESS: AIR PERMITNO.05100204
19750 AUBURN DR
!ER'S NAME: PERMIT ISSUE DATE
DONALD ANDERSON 1701 LITTLE ORCHARD ST 10/25/2005
PHONE: SANITARY NO. CONTROL NO.
(408) 291-2220
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�Oo LICENSED CONTRACTOR'S DECLARATION Job Description
F 1 hereby affirm No,l am licensed under provisions of Chapter 9(commencing
`�' wiN Sation 7IXk0 of Division3 of NC Business and Professions Codc,and myliccnu is REPLACE FURNACE
in full forte and effect.
Lites Clan IC.a x
Dale Ey �F
p
ARCHITECTS DCLARATION k6 !
Cyy< 1 understand my phnsebail be used ss Public recordsslail
DWU ,
;�� LiccoscO Professional /'ry� "a'p"D®
3 OWNER-BUILDER DECLARATION y
I hereby affirm Nat I am exempt from the Conuacto's License Law for the `l
00 following reason.(Section 703 1.5,Business and Professions Code:Any city or county b / n
$ which acquires a permit to concoct,alcor,improve.demolish.m tepair any 9rumum N'fi vl 7gns $2400
_z i prior mill issuance,also pictures the applicant for such permit to file a signed statement — II �(
< that he u licensed pu.set to the provisions or the Contractor's Liaitu Law(Chapter 9 Sq.Ft. Floor Area 7!✓ (V,i`� Valuation
y�a (Commencing with Section 7000)of Division 3 of the B ounces and Professions Crack)or
y $ that he is exempt therafrom and the III for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicanuo a civil penalty of er `Ocedpancy Type
not more Nan five hundred dollars(5500). ���'
I,as owner of d,e Property.or on,employees with.,,u their sole Compensation,
will do the work.and the structure is notntended or offered for sal(Scc 704.Business -
uM;Pmfessrans Code:the Contractors Licensee Law does not apply m an evancr or, - — —...-Required
Inspections_
property who William improves ovc ,and whoddessuch work b,msdfor through his s -I
I
awnemploym4.pmndedN to ch' provemenu ve noiimended uroffeked far If.
hrwevcgthebmldmg orimprorcmcnt isuld wiNm one)ell of cbmplcdan.Ne
I ;builder wilt low O__b ordrm of piovirip tAaThe did nm build or,mProvs(or purywc of I
t satcJ. t
owner.oLde.propenY•am eacludvdy convecting wiN.lianud convaaors mi ._....._..__.___-___....__.__.—_.__.___.._..._.__.__ ..._._ '__..............._....._...___._._...._..._._._...._-.___.
w amcl Orepmjcm(See.7004.Business and Prohosol Code:)The Comramors Li.
i close Law does nut apply to an owner of propcay.who Wilds or improves demon,and
who contracts for such prpi'mwith aconuu_tor(s)liccnxpursuantm
d m me Conuaofa',
LieenYl2W ... ._.. ._ .. _ _. ... 1 .,TA .._. N 10.
.._. .
❑1i turd c .h-9 PC far is¢ ..I '
1k !Q --
-Data
tos'sl�_ ,e "K RS COM ON DECLARATION i f _UI:C t 17.,..
i^Ah MECIS
I hereby affirm under penalty or perjury res of the following dectratiose I f'_i �'_ - "
o;
C„� �Iham end will moinuinaCcni0camo(Conunua ulLinartlar Workcts Compcn:� f 1 ;qtr^:".I;ipti
cation:as provided far by SCI 3700 of Ne Labor Coda for.d,e pedormameml Nu _
,work for,whieh Nis permit is hated:;u:"'::.ec,::.a!axm-..:::rk.
- i t]'I Iieve eriA will maintain WohWs Compensation Insurance,Is required by Section
3700 of the Labar Code:for 0e perfooreamc of die''vidh for which-this permit is iscued.t
MY Wbheh CmmpensmimvinsunnuTarticr"irid Policy number ares-
'! Cartier:-."trs:
____._.CERTIFICATE OFEKEMPTION FROM WORKERS'—___.__._ 1
��- ✓r.s.e-: COMPENSATION INSURANCE !
mend
not Incom l:acdilibepax:an7fore 1
•(Ilius action nerd not WcomplemJ if the pem,it is foronc hundred ONbrs(SIW). -
a•. yglgs 1 a f n 0 t ,Co h y mercy
it
I clktif,thu to Nc perfhfma of thye,work for h ch N_ R. tis aa d I shall roti -----
_ _
on
employ any persto any aJ�/-4 bcCAhe sublen to Ole Wo kart CompLnsailan) i'aAI iC2 Yr_Iah:I•i4
Laws of Cahfo
v� Applicam " tet ' v _ L _ _. . ._,_.. ._.
t NOTICE TG APPLICANT If alta koyf this Ccef,ateol geemdo you'ih sulJ ..._._ _ L_.. . _ - ----- - - ---
heloma subJenm the Vlorkcn ComPcidntian pm slonf of Ne"Labor Cod you do \_ r r -+..illi b." t t.t'1Lar , iyii6
.J'Z fonhwnh eomPly with to ch Prwi let or Nis permnshall he lamed revoked. I
h ,I.v a LCCONSTRUCTION LENDING AGENCY - ,3t•,r p 1 --- '- '� "y - -
'T. Y mNcm sato awcl I d gagpruy Tomlin N,furmxrnxufl .. -. ....
r
Ihemb uMms th i
C4 '✓ .the w�rk(6,whch ihtp DCtmmis issued sal 31197 Ci C).;. If. e.,,..,pys
W� Q lkntlefs Name .. . . ..
Irndcfl ceNf Neki h
U 1,7 y dose rnE tAu iPPlidal on and sate Net dre ibS"vc infoimStlon u! -. J:i r ---
f” Corcu 1 agree t comply th all city and co my oNtnarees and suit laws rclat ng to,
L4 building eomstmcun,and hereby eutboria<representatives u(ths city to entrpon the .-.. __ _ - ..... _...__.__.. ._..
r ahpv5 menta 4 progeny for rupcction
G c;;, (We)agree nuc mdcmndY,a^d kap harmless the City,o(Cuputmo:aga nst.
cq abil da ludgm,nu,Coxes and clificromwhich may in any way attrve aga net send City1
V Z M Conduct; c of Nc Sranung mf Ms perm t _. .. I ._ _. -
t APPLICANT�UNDERSTANDS AND WILL COMPLY WITH ALL OA.POINT Issued by: ' Date ✓=0 '/�
i sou uLA1s � rD�J�I'0 Re-roofs'
I Sr oat c ol'ApplicanpIcAtrallor WT _
Type Of ROOF
vHAZARDOUS MATERIALS DISCLOSURE il > ,
Will Ncappl caroti fl bildngoccupant stp or handle hazardous material -
t as defined by d¢G pent o Mun mlldfChdc Chapter 9 11-k d Nc Heald,and safety -_ _ --- l i . 1); .
c.&6 6 ssn(s)a' All roofs shall be inspected prior to any roofing material being Installed.
-twJ❑Y 4 # ire �Na 7 !I
' t t 1- t n-! -If a roof is installed without first obtaining an inspection,I agree to remove
i)y tW 11 m p'1 ant f t m.building_ f t 1.}c q.Pm m a do s. h ch
! emil u de s conwm an u d fncd by me 6 y ArtaA Quality M 6 otI all new materials for inspection.
tl D'um7 t \ ,
ti. ❑Y s ,a Ne q. ll
! di.H l &SafCyC.dC.SCaml2550ale mGgiRlr,ehtlmlder Chapter d.95ofNe Ciddingt
aHcal cur Safny Codc 5 cu shat 2557oe n 25574 1 rsmnd ih l fthc W'Idi g!
does nc cone Oy hive`a¢rani.that ii is'my rcspom d ISy to n my the r fbii df too;
icy 1 , t poo miss once f Ccmfcam of CcuPan
.,1�•„ r �[ >P - r„ . -, - _r Signature of Applicant Date
t _.----._ s - _
All roof coverings [o be Class'B" or bctttter.'.�^;
CITY OF CUPERTINO
I 1 of 1 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 31635017.00
DATE ISSUED. . . . . . . : 10/25/2005
RECEIPT #. . . . . . . . . : 31733
REFERENCE ID # . . . : 05100204
SITE ADDRESS . . . . . : 19750 AUBURN DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : DONALD ANDERSON
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-2414
RECEIVED FROM . . . . : STEPHEN ANDERSON
CONTRACTOR . . . . . . . : RICHARD READ LIC # 22334
COMPANY . . . . . . . . . . : CONDITIONED AIR
ADDRESS . . . . . . . . . . : 1701 LITTLE ORCHARD ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408) 291-2220
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 2,400,00 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 164.78 1056
TOTAL RECEIPT 164 .78
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL
0
Community Development
10300 Torre Avenue
}�. Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
PEkTINO
Building Department
JOB ADDRESS: (g3-5b Py, b UZJ I) r 1.,je PERMIT #Q�����
OWNER'S NAME: D u rjbE-RSO r,) PHONE # p
GENERAL CONTRACTOR: FAX # A SSS 6 T
i
1 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 Co v 9 I'7 a N> p i K
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
o Tile
_ io -aS"-aaai—
Owner/Contractor Signature Date
CITY OF CUPERTINO
0 l(� FURNACE/AC
CITCUPEkTINO PERMIT APPLICATION FORM
APN # ,,- Date:
�S/ D/ 7 ro CDD �
Building Address:
' - $o )C�VC2N rt e
Owner's Name: Phone #:
Do q-J N ..0 22-2 o
Contractor: License #:
I-/L/ S / 6 -2
Contact: pp Cupertino Business License#:
L-2R 33
Building Permit Info: C
Bldg ❑ Elect P1umbCZL_ Mech
Job Description:
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1" floor � 2"d floor❑
Adhere to min set back 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: Occupancy group:
00 L/N tL_3
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN 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
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