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07050004 CITE'OF CUPERTINO BUILDING DIVISION PERMIT C0 .F'ORMA'TIoN r PERMIT NO. BUILDING ADDRESS: 10992 NORT1499AL SQ PER I OWNER'S NAME: CONDIT10NING AVE SANtVYY Ud 2 U Ul CONTROL NO. BUILDING PERMIT INFO ARCHITECTfFNGINEER: BLDG ELECT PLUMB MECH C� 0 j LICENSED CONTRACTOR'S DECLARATION ADD A C' Job Description I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force S?w Licen-se�CI�andc �t / — LIC. Date Con tractr ARCHITECTSDECL N / -� I understand my plans shall he used as public records d F� Licensed Professional - ----� --- -�--- 'a OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the j o following reason.(Section 7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure prior to its issuance,also requires the applicant for such permit to file a signed statement Sq.Ft. Floor Area Valuation < that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 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 APN Number Occupancy Type not more than rive hundred dollars($500). ❑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 Contractor's License Law does not apply to an owner of 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 Contractor's Li- 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 Contractor's License Law. ❑1 am exempt under Sec. B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: have and will maintain a Certificate of Consent to self-insure for Worker's Compen- .-..mon,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Workers Compensation Insurance carrier and Policy number am: Cartier 111.01 Policy No. CEETIFICA OF EXEMPTION FROM WORKERS'T COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued.1 shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California.Dale 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 Z forthwith comply with such provisions or this permit shall be deemed revoked. O CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a constructinn lending agency for the performance of the work for which this permit is issued(Sec.3097,Civ.C.) QLender's Name Lender's Address Q 1 certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to Ubuilding construction,and hereby aulhorim representatives of this city to enter upon the W above-mentioned property for inspection purposes. Clw (We)agree to save,indemnify and keep harmless the City of Cupertino against Ci] liabilities,judgments,costs and expenses which may in any way accrue against said City Z in consequence of the granting of this permit. Date 04 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SO CE REGULATIONS. 1/l fe:2.rw,..__ D3 Re-roofs ignature of Applicant/Contmetor Dare Type of Roof HAZARDOUS MATERIALS DISCLOSURE 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 Safely Code,Section 25532(a)? All roofs:hall be inspected prior to any roofing material being installed. ❑Yes o /` If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. strict? ❑Yes o 1 have read the hazy materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building does not currently have a tenant,that it is my responsibility to notify the occupant of the requi ms which must be met prior to issuance of a Certificate of Occupancy. Signature A Applicant aDate / c e I/Lt rdj s'-�'i",0,) All roof coverings to be Class"B" or better O ncr or authoriz d agent _ CITY OF CUP3RTINO PERMIT RECEIPT OPERATOR: suew 8 ITEMS OF 24 COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 31640C36 .00 DATE ISSUED. . . . . . . 05/01/ 2007 5000( 01167 RECEIPT #. • • • • . • . . 07050(iO4 REFERENCE ID # • • SITE ADDRESS 10992 NORTHSEAL SQ SUBDIVISION • • . . . . : CUPER'IINO CITY . . . . . . . . . . . . IMPACT AREA . . . . . . . OWNER REINECKE ROBERT C ADDRESS CUPERTINO CA, 95014-0532 CITY/STATE/ZIP . . RECEIVED FROM RECEIPT INTERFACE CONTRACTOR RANDC1, JIM LIC # 8050 COMPANY . . . . . . . . . . : AAA FURNACE & AIR CONDITIONING ADDRESS 1712 STONE AVE CITY/STATE/ZIP . . . : SAN 'FOSE, CA 95125 TELEPHONE (408, 293-4717 _ UNIT QUANTITY AMOUNT PD-TO-DT THIS REC --NEW-BAL- FEE ID ---------- --- ---- ---------- 0 .00 - ------------- --- 34 . 86 0 .00 34 .86 1.00 0 00 10 .26 0 .00 BENERGY PERMIT FEE 1.00 10 .26 0. 00 BREMAIRHAN NO.UNITS 14 .31 0 .00 14 .31 NO UNIT 1.00 0 .00 1.20 0 .00 BREMFURN 1 .00 1.20 0 . 00 BREMRECEPT NO. OUTLETS 0 .60 0 .00 0 .60 5, 693 . 00 0 .00 38 .37 0.00 BSEISMICRE VALUATION 1 .00 38 .37 0 .00 EPERMITFEE FLAT RATE 1 .00 38 .37 0 .00 38 .37 0 . 00 MPERMITFEE FLAT RATE 38 37 0 .00 38 .37 1 .00 -- PPERMITFEE FLAT RATE -- ---------- -- ------- 0 .00 176 .34 0 .00 176 .34 TOTAL PERMIT VOICE ID DESCRIPTION DESCRIPTION - VOICE ID - --------------------- _ ------- ------- -- ----- 304 ROUGH ELECTRIC AL 303 ROUGH MECHANICAL 505 FINAL ELECTRICAL 508 FINAL MECHANICAL CITY OF CUPERTINO FURNACE/AC SR.UPE TING PERMIT APPL[CATION FORM T APN # ` Date: �4//0 Building Address: Owner's Name: Phone#: Contractor: Phone: License M Contact: Phone: Cupertino Business License#: Z Building Permit Info: Bldg ❑ Elect :'lumb ❑ Mech Job Description: Residential P Commercial ❑ For Residential Installations: Attic ❑ 1" floor P 2nd floor❑ Adhere to min set back requiremen For Commercial Installations: Replacement same weight ❑ Additional weight (s:ructural calcs) ❑ Structural Calculations required for new installation ❑ New installation Planning Approval Required ❑ Cost of Project: Type of Construction: Occupancy group: Strapped Ef On Platform LJBonded Cl Sq.Ft. Floor Area: New Location ❑ Replacement Qty. if Applicable Fee ID Fee Description Fee Group BENERGY EnergyBUILDING BREMFURN furnace MECHANICAL BREMACOVER Y1/C Unit> 10,000 cfin MECHANICAL BREMAIRHAN Y Units<= 10, 000 cfm MECHANICAL BREMRECEPT I:ecptl, Switch & Outlets ELECTRICAL BSEISMICRE I>eismic Fee Res BUILDING BSEISMICOM Seismic Commercial BUILIDNG EPERMITFEE Ellec Permit Issuance ELECTRICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPLANCHK flan Check Fee BUILDING BPGAS Gas Piping System Fee PLUMBING BUSLIC Business License BUILDING Community Development g: 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 �.UPEkTINO Building Department JOB ADDRESS: PERMIT # OWNER'S NAME: Z4 ±:-, - /f-/-�F C < C- PHONE # o - c � GENERAL CONTRACTOR FAX # I am not using any subcontractors: Si;;nature 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/Co tractor Signature Date