09010040 CITY OF CUPERTINO
BUILDING DIVISION PERMITITRA�'CT + � " "
BUILDING ADDRESS: PERMIT NO.
7613 ERIN WAY AAA FIJRNA('F k ATR ognionAn
OWNER'S NAME: CONDITIONING PERMIT ISSUE DATE
MHO SA CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
REPLACE FURNACE 80, 000 BTU
o c LICENSED CONTRACTOR'S DECLARATION Job Description
v I hereby affirm that I am licensed under provisions of Chapter 9(commencing
_Z with Section 7000)of Division 3 of tite Business and Professions Code.and my license is
in full fora and ect 12 4 tap 21
License Clan ef C •
Date Contractor
CHrMC7'S DECLARA
I understand my plans shall be used as public records
�yU
CH Licensed Professional
y 3 OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
aO following reason.(Section 703 L5,Business and Professions Code:Any city or county
y 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
z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 $q.Ft.Floor Area Valuation
XF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i 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 five hundred dollars(5500).
❑I,as owner of the property,or my employers 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.).
❑1.as owner of the property.am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractors 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.
[31 am exempt under See. B tit P C for this mason
'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 Workees 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 Worke C ruadon Ins nue n 'cr and Policy number arch�:�LL��
came; Policy No.: r.1,Z_ I
7ROMFICATE O CEMPTION FROM O KERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for oue 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.
Z 0-4CONSTRUCTION LENDING AGENCY
[~.r rA I hereby affirm that there is a construction lending agency for the performance of
a the work for which this permit is issued(Sec.3097,Civ.C.)
W�,0 Lender's Name
a z Lender's Address
U 0 1 certify that I have read this application and state that the above information is
LL correct I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes
O r (We)agree to save,indemnify and keep harmless the City of Cupertino against
„.,4 liabilities,judgments,costs and expenses which may in any way accrue against said City l /r
U Z in consequence of the granting of this permiL Date
r"r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
,J lei ,-wr+r•� f�T/� Re-roofs
Sign a5t re ofAppli UCo DatE' 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 Safety
rode,Section 25532(a)? `l All roofs shall be inspected prior to any roofing material being installed.
C356
Yes .
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
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
1 have read the hazardaus materials requirements under Chapter 6.95 of the Califor-
nia Health k Safety Cade,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
req;jmcnts which must be met prior to issuance of a Certificate of occupancy. Signature of Applicant Date
J( `t�— All roof coverings to be Class".. 'or better
Owner or authorized agent bate
Community Development
10300 Torre Avenue
S�a_
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
t;UPERTINO
Building Department
JOB ADDRESS: PERMIT #
OWNER'S NAME: L?ti PHONE #
GENERAL CONTRACTOR: cry FAX #
I am not using any subcontractors: /► -L- Q! -o.� -v -
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
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN 35920017 . 00
DATE ISSUED. . . . . . . : 01/09/2009
RECEIPT # . . . . . . . . . : BS000006943
REFERENCE ID # . . . : 09010040
SITE ADDRESS . . . . . : 7613 ERIN WAY
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER DONNA JAHN
ADDRESS 7613 ERIN WAY
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : JIM RANDO
CONTRACTOR RANDO, JIM LIC # 8050
COMPANY AAA FURNACE & AIR CONDITIONING
ADDRESS 1712 STONE AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE (408) 293-4717
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----
1BCBSC VALUATION 2, 730 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 2, 730 . 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 225 . 85 0 . 00 225 . 85 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 225 . 85 VISA
---------------
TOTAL RECEIPT 225 . 85
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- -----------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
CITY OF CUPERTINO
FURNACE/AC
CUPERTINO PERMIT APPLICATION FORM
0 6 094D
APN# Date:
ZO 017, 06 D/Df - o ��
Building Address:
Owner's Name: Phone #:
. �40 W- 99� - ;� Y3,r
Contractor: Phone #:OW.05;--7._
C Fax #:
Contractor License#: ' Cupertino Business License#:
Contact: Phone #:/!per. 9-7 , �f 71
2 GSC. Fax #:
Building Permit Info:
Elect Plumb ❑L-- Mech [�
Residential Commercial
Job Description:
/of Ila c e- �v/A Q C a 61�1-1 POO 417-4)
For Residential Installations:
Attic ❑ 1 s` floor 2"d floor E:1
Adhere to minimum setback requirement ❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Coit of Project: Type of Construction (Usage Class):
X73
Strapped On Platform Bonded F1 New Location Replacement
Li
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
CITY OF CUPERTINO
FURNACE/AC
CUPERTINO FEE SCHEDULE
Grou
FURNACE FURNAC
1 PGASRES Residential for ea gas piping system of P
1-4 Outlets
IBPGAS For each gas piping system of 5 or P
more per outlet.
1BSEISMICR Residential Seismic B
1 MECPLNCK Mechanical Plan Check M
1MFR=<100 Furnace Syst<=100k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance up to and
include 100,000 Btu/h
1MFRN>100 Furnace Syst> I00 BTU install or M
relocate ea forced-air/gravity type
furnace/bumer, incl ducts/vents
attached to such appliance over
100,000 Btu/h
1 EPERMITFEE Electric Permit Fee E
r 1MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit P
I �vt R2A-�
1TRAVDOC Travel Documentation B
1BUSLIC Business License B
Quantity-T Fee ID Fee Description Fee Permit Type
INPUT Resources Energy 'Q
n oor it ua ity and rms es
1.Use Low/No-VOC Paint 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3.Use Low/No VOC Adhesives f 3 IAQ/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7.Seal_all Exposed f,articleboard,orMDF 4 IAQ/Health pts y=yes 0
8.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes jo 9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes [7770
1 ! 1
N.Flooring
1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0
2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
1 ! !
Total Points Avai ab e: 1 1401 1301 57
Total Points Project Received: 01 01 0
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