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06100146 CITY OF CUPERTINO BUILDING DIVISION PERMIT BUILDING ADDRESS: VALLEY HEATING & COOLING PERMIT No. 0 610 014 6 21721 COLUMBUS AV PERMTT ISSUE DATE OWNER'S NAME: WALTON JOSEPH ,NE: SANITARY NO. CONTROL NO. 408 2 94- ABUILDING PERMIT INFO RCHITECT/ENGINEER: BLDG ELECT PLUMB MECH o p LICENSED CONTRACTOR'S DECLARATION Job Description U P I hereby affirm that I am licensed under provisions of Chapter 9(commencing Z w with Section 7000)of Division 3 of die Business and Professions Code,and my license is yin full force and of c License C Lic•# OQ� O REPLACEMENT OF FURNACE & A/C Z G [- Date Contractor ARCHITECT'S DECLARATION C< I understand my plans shall be used as public records >�U .a :O Licensed Professional n OWNER-BUILDER DECLARATION '> 1 hereby affirm that 1 am exempt from the Contractor's License Law for the :00 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 structureRenn Zy prior u)its issuance,also requires the applicant for such permit to file a signed statement _ that he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9 Sq. Ft.Floor Area Valuation t- (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 3AIK1Rifi fir. 0 0 Occupancy Type not more than five hundred dollars(5500). ❑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 q P 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 I hereby affirm under penalty of perjury one of the following declarations: ❑I have and will maintain a Certificate of Consent to self-insure for Workces Compen- sation,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 Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Work�Compensation Insurance carrier and Policy number are: Cartier. rN4 Policy No.:,20 Y10I�G ♦' CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued.1 shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must ,J O forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of tx> the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lender's Name =Z L.endees Address U 0 1 certify that 1 have lead this application and state that the above information is LL►-r correct.I agree to comply with all city and county ordinances and state laws relating to 0 U building construction,and hereby authorise representatives or this city to enter upon the above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against Co) liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. ► Date APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SO$E REGULAFOANS. (91,. Re-roofs -� Sig QW6 A Contractor ate // HAZARDOUS MATERIALS DISCLOSURE Type of Roof 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 Safety Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes ❑Na 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 omit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes ❑No I have read the hazardous 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 require h must be MCI rior w issuance of a Cenificate of 9cc ancy. Date -�✓'— _ Signature of Applicant �T`�-'�^7-- All roof coverings to be Class"B"or better Ow r authorized agent Date CITY OF CUPERTINO lcem 1 of 1 PERMIT RECEIPT OPERATOR: kiersaw COPY # 2 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 35618038 . 00 DATE ISSUED. . . . . . . : 10/19/2006 RECEIPT # . . . . . . . . . : 36495 REFERENCE ID # . . . : 06100146 SITE ADDRESS . . . . . : 21721 COLUMBUS AV SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : WALTON JOSEPH H AND FAITH C ADDRESS . . . . . . . . . . . CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4775 RECEIVED FROM . . . . : VALLEY HEATING & COO 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 - --------- ------------ - ---------- ---------- ---------- ---------- ---------- BREMAIRHAN NO.UNITS 1 . 00 10 . 26 0 . 00 10 . 26 0 . 00 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 9, 000 . 00 0 . 90 0 . 00 0 . 90 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 175 .44 0 . 00 175 .44 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- ------------ ------------------ CHECK 175 . 44 15375 TOTAL RECEIPT 175 .44 VOICE ID DESCRIPTION VOICE ID DESCRIPTION 301 ROUGH PLUMBING 303 ROUGH MECHANICAL 04 ROUGH ELECTRICAL 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL Proposed Layout for: NAME .,� a {-t, fTIS ADDRESS ES PHONE NO. , ESTIMAjOR Tt TE Scale 1/4"_ 1 2 3 4 5 6 7 8 9 loll 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 � _ 3 ' 4 5 6 7 9 ff� 10 I 12 13 14 ,}f,, k.t t 15 >~ ' 16 17 r 18 ~ � 19 20 21 r 22 23 24 25 +oyes Materiaia I Labor '1aX Total :.. 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