08100154CITY OF CUPERTINO
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BUILDING DIVISION PERNIIT
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BUILDING ADDRESS:
PERMIT NO.
7576 SHAD
LAS—
OW NEWS NAME:
PERMIT ISSUE DATE
SA CONTROL NO.
ARCHI'IEC teNGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
R&R FURNACE
LICENSED CONTRACTOR'S DECLARATION
'
Job Description
p
1 hemby amrm dust 1 am Ilmmed under Pmvidoru of Chaplin 9 (Commencing
with Section 7111MB O(Dividon 3 of the BudhevaM ProfcsdoM Code.aM my Icertse u
in full fenw and c 9_
,
Lioenm I.ie Lm. g C
Dau L� Conuanor
ARCHTIECTS DECLARATION
I underaanJ my Plans slWl W used u public ramrN
'
Licensed professional
OWNSR-BUI DER DECLARATION
I hereby eRsm Not l am cxempt from tits Contractors License Law rot the
following mason. (Section 70513, Business and Professions Code: Any city or county
which myulrcs a Permit m conarom, slur. hnpoom, demolish. m repair my structure
Prior m its issuance. alas mquims Ne applicant for such permit m file a signed stateroom
Sq. Ft. Floor Area
Valuation
dustlrciancensedpulmmlmwepm.uinmerthe CormacmrsUmnmLaw (Chapmm9
(commencing with Section 7000) of Division 5 of use, Business and Professions Code) or
Nal he u cxempt dmmfmm and the hmu for the alleged exemption. Any violation of
APN Number
Occupancy Type
section 7031.5 by any appHearm for. Permit mbjecu the applicant m a civil penalty of
rml more than rtvo hundred dollars (55101.
❑ L u mwwnr of cite pmpmty, oe mY wPlaym with wage u de'vmm Compewtion,
Required Inspections
will do thework-and the common u ootinteaded oeoRertE fmsam(Sec.70M, Budk.•
and Profnssians Code: The CnnmcmYs License law does an, apply m an owner of
property who builds mimpmvea Hereon, and who doessuchworkhmoso fmthrough his
oweemploycM, provided that such imp�manu are not intended moRered forseh: H,
however. the building or improsmem u sold within own Sas of eempletion, the, owoen-
buiWm win have the buten of proving that M did toe ddb a improve for puryose of
Q 1, as owner of the property ant exclusively contacting with licnmed Co nsta ors to
construct the project. (Sec. 7014. Business and Pmfexsions Code:) The Commences Li.
come Law does not apply m an owner, of Nvporty who builds or improves demon, and,
.
_
who commma for such projects with a convxmr(s) licensed punuam m the Conuators
License law.
❑ l ane exemptuedm See , B & P C for Nu reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 Wintry alum under penalty of perjury oro of the following decdv0otu:
Ihartand will maintaina Ce FLmuofComenttemlf-in mfmWohersCompcn-
Hon, as provided for by Section 57M of the Labor Code. for the performance of the
wmk or which this permit is bound.
have end will malntaln Workers Compensation I.. as to,m it by Section
5 mthe laWor Cade. for the pcRorman¢o(tie wmkfor. ve this permit u issued.
y Warke/Y,s huunnaonivmditheymook'sm:
(entre/q�mm
tinier. , /L - g Polity No.:
CERTIFICATE OF EXEMPTION FROM WO
COMPENSATION INSURANCE
(Thlssecoom need Out W completed brute pmmh him= hundred de0ars($]W)
'
or hers)
I mol that in duo porfmmmm of the work for which this permit u issued. I shall not
Cmploy any,.. in my mmMrSn ar m bemarm subject to ftWorked Compensation
Lawn; of California. Dam
.
Applicant
NOTICE TO APPLICANT: IL ager readng this CeroOnm of Eaemptien, you should
become subject m me Workers COmpcmddon providom of the LSWm Cade, you must
comply with such provisions m this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hemby affirm thus them u a mmuocti er lending agency for the perfarron¢ Of
du work for which this permit d issued (Sec. 5097. Chi. C.)
"
None
Lamices Address
I certify the, l have mad this application and sum Nat the above information is
Corms 1 agree Or comply with all city and county ordinances sed sum laws resting in
Wilding coMuuction. and hemby authmim mprescnutives of this city to murupon the
show-mentiawnd Intercity for impaction Puryoiev
(We) agree on saw, indemnify and kecp tattiness the City Of CYperomi agaiml
liabilities, Judgments. cont and expenses which may In my way accrue against said City
n coMegoe a of the grand of this Pcrmi1
'A
APPLIC N AN AND WILL COMPLY WITH ALL NON -P INT
Issued by: Date �G �2
....
Re -roofs �!.
Type of Roof
m
Signuum of ApplipHAZARDOU
HAZARDOUS MATERIALS DISCLOSURE
WIIINe mtorforum Wildingacupmtnmeor handle
unrctpal Cade. Chapter 9.13, and the Halth and Safety
m dented by tie Health and
32(a?Common
Code, Scotian 25572(a)T
All roofs shall be inspected prior to any roofing material being installed.
❑ Ym o
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant Or future Wilding occupant use equipment or devices whim
ash hrnrdnm air canuminanu a defined by the Bay Area Air Quality Management
all new materials for inspection.
,Met?
❑See ❑
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor.
.is Heaith& Safety Code Sections 25505,25555 and 25534.1 undersuntl mmif tits Wilding
doca Ml curmnLlY Haut a MMM4 OM i, u mY mspaMiH]ily b rwdry the accuPmt Or the
nuw' Wemelpiormissuanaorar^";nesuof
Signature of Applicant at
All roof coverings to be Class'W' or better
Date
of on roma
• 6 ITEMS OF 12
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ......... 36224030.00
DATE ISSUED.......: 10/23/2008
RECEIPT #.........: BS000006450
REFERENCE ID # ...: 08100154
SITE ADDRESS .....: 7576 SHADOWHILL LN
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: patg
COPY # : 1
OWNER ............: SREEHARI NARASIMHAIAH
ADDRESS ..........: 7576 SHADOWHILL LN
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-5052
RECEIVED FROM ....: ATLAS-TRILLO
CONTRACTOR .......: TRILLO, STEVE LIC # 4269
COMPANY ..........: ATLAS-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
1BSEISMICR
VALUATION
1,700.00
0.50
0.00
0.50
0.00
1EPERMITFE
FLAT RATE
1.00
40.79
0.00
40.79
0.00
1MPERMITFE
FLAT RATE
1.00
40.79
0.00
40.79
0.00
1MRRAA
UNITS
1.00
61.19
0.00
61.19
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
224.85
0.00
224.85
0.00
VOICE ID DESCRIPTION
-------- ----------------------------
505 FINAL ELECTRICAL
508 FINAL MECHANICAL
VOICE ID DESCRIPTION
-------- -------- -------------------
507 FINAL PLUMBING
•
N
Buil
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
artment
JOB ADDRESS: SCc Sk�Gr'o�l� rl� PERMIT #
OWNER'S NAME: ,sYtekGt -, fiayd ,pl',R A,,Zl'cd, I PHONE # -4/.4
GENERAL CONTRACTOR: 44t17 f —7-W 11 n -l-(1 A- l IFAX#
I am not using any subcontractors: 6N� 2U k
Signature Date
Please check applicable subcontractors and complete the following information:
INZ-4
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Date
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
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Date
4
or
SCUPEI�TINO
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L.
CITY OF CUPERTINO
FURNACE/AC
PERMIT APPLICATION FORM
09/ 0D/ �y
APN # 03 V/\ 1 00
Date:
Building Addre :
5-
Owner' Na e n ^
Phone 4(',,
Contractor: t l (� S j M %0..Q
Phone #:
DSL
�o f 1 C
Fax 4:
Contractor License #:
Cupertino Business License #:
Contact:
Phone #: may_ GSA
Z
Ay,kv
Fax #:
Building Permit Info:
Elect Plumb D— Mech IT
Residential Commercial
Job Description:
��pp
4 �.
For Residential Installations:
Attic ❑ I" floor ❑ 2"d floor ❑
Adhere to minimum setback re uirement
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction (Usage Class):
b v�
Strapped H On Platform ❑ Bonded ❑ New Location ❑ Replacement
Project Size: Express ❑ Standard ❑ Large ❑ Major ❑
Valuation:
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index. �\
Revised 6/16/08
CGS-
CI OF
CUPERTINO
CITY OF CUPERTINO
FURNACE/AC
FEESCHEDULE
Quantity
Fee ID
Fee Description
Fee
Permit Type
Group
FURNACE
FURN/AC
1MCRAA
Commercial-Repair/Alteration/Add to
M
ea heating appliance,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,absorption or
evaporative cooling system,incl
installation of controls regulated by this
code.
1MCREPALT
Commercial for the repair of alt/add to
M
ea heating appliance,refrigeration
unit,cooling unit,VAV boxes,
absorption unit or ea heathing, cooling
absorption,or evaporative cooling sys,
incl install of controls regulated by
this code.
1MCSUSHTR
Commercial Install/Relocate ea
M
suspended heater,recessed wall htr, or
floor mounted unit heater.
1PGASCOM
Commerical for ea gas piping System
P
1-4 outlets
IBPGAS
For each gas piping system of 5 or
P
more per outlet.
1MCAPPVNT
Commercial for the install/relocate/ or
M
replacement of ea appliance vent
installed & not incl in an appliance
permit.
IBSEISMICO
Commercial Seismic
B
I MRRAA
Residential Repair/Alteration/Add to
M
ea heating appliance,refrigeration unit,
j
cooling unit,absorption unit,or ea
Iheating,cooling,absorption
or
evaporative cooling system,incl
installation of controls regulated by
this code.
1MRSUSHTR
Residential Install/Relocate ea
M
suspended heater,recessed wall htr, or
floor mounted unit heater..
IMRAPPVNT
Residential for the install/relocate/ or
M
replacement of ea appliance vent
install & not incl in an appl permit.
Quantity
Fee ID
Fee Description
Fee
Permit Type
Grojin
46
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