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10010135 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19765 AUBURN DR CONTRACTOR:AAA FURNACE&AIR PERMIT NO: 10010135 CONDITIONING -NER'S NAME: NANCY LOVEJOY 1712 STONE AVE DATE ISSUED:01/25/2010 OWNER'S PHONE: 4087995250 SAN JOSE,CA 95125 PHONE NO:(408)293-4717 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class ZV Lic.# -7) r— r ,^`� G MECH RESIDENTIAL COMMERCIAL Contractor G /3-e� Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALL 40 GALLON WATER HEATER (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$980 1 have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:31632008.00 Occupancy Type: APPLICANT CERTIFICATION I 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this pe it. d 'tionally,the applicant understands and will comply with all n n-po t our r ulations per the Cupertino Municipal Code,SectionDate: CU y:-. -��- _.,._ yr�.. 9.18. Issued b S` -ature Date ,— RE-ROOFS: ❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined b the Bay Area Air Quality Management District I will maintain complian a Cupertino Municipal Code,Chapter 9.12 and the permit is issued. V I certify that in the performance of the work for which this permit is issued,I shall Health&Safety S tions 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Owne )orut or agent: j Compensation laws of California. If,after making this certificate of exemption,I Date: become subject to the Worker's Compensation provisions of the Labor Code,I must 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 work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter Lender's Address the above mentioned property for inspection purposes.(We)agree to save .inify and keep harmless the C' of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which ma c e against said City in consequence of the granting ofthis permi d ' on y,the applicant understands and will comply I understand my plans shall be used as public records. with allgo-poi urc tions per the Cupertino Municipal Code,Section 9.18. / Licensed Professional Signature Date CITY OF CUPERTINO 5 ITEMS OF 31 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 31632008 . 00 DATE ISSUED. . . . . . . : 01/25/2010 RECEIPT #. . . . . . . . . : BS000009610 REFERENCE ID # . . . : 10010135 SITE ADDRESS . . . . . : 19765 AUBURN DR SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : NANCY LOVEJOY ADDRESS . . . . . . . . . . : 19765 AUBURN DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : RANDO AAA HVAC, INC 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 980 . 00 1. 00 0 . 00 1 . 00 0. 00 1BSEISMICR VALUATION 980 . 00 0 . 50 0 . 00 0 . 50 0. 00 1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0. 00 1PRWHEATR UNITS 1 . 00 25 . 00 0 . 00 25 . 00 0. 00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 .00 42 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 110 . 50 0 . 00 110 . 50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 935 . 90 #35494 --------------- TOTAL RECEIPT : 935 . 90 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CUPERTINO WATER HEATER CUPERTINO PERMIT APPLICATION FORM ��Urd/�3s APN # Date: c3� �P Building Address: Owner's Name: Phone #: Aft�l,r V � gp-- Contractor: Phone a , . 671-71 . (&12,90 C /i�C Fax #: Q Cupertino Business License #: Contractor State License #: Contact: Phone #: /Q,�- a!F3 ' y7/,7 Fax #: 2l3 -lo �7/ Building Permit Info: 16,o� le� 1�pa Bldg ❑ Elect ❑ Plumb 10� Mech 1:1 Residential [l� Commercial ❑ Solar ❑ If solar, number of kilowatts: Strapped On Platform ❑ Bonded New Location Replacement Valuation (cost of project): qp0 /d Project Size: ExpressEJ Standard 0 LargeF-1 IV ('OVw i�r 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. Green Building Points achieved: Revised 08/20/09 R CITY OF CUPERTINO T WATER HEATER CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Permit Type Group 1PCWHEATR Commercial Water B PCWHEATR Heater/Vent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICOM Seismic Commercial B t 1PRWHEATR Residential Water B PRWHEATR Heater/Vent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICRE Seismic Residential B / 1 PPERMITFEE Plumbing Permit P 1TRAVDOC Travel & B � Documentation 1BUSLIC Business License B Community Development { 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY.OF Fax(408)777-3333 .%U PEkTINO Building Depart ent JOB ADDRESS: A u,b r-u r j PERMIT # A� j OWNER'S NAME: Nn v� PHONE # der - 7 2-5oGENERAL CONTRACTOR: -� , ,,`., c-Yd o A FAX # I 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 Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet ck' Til� Y —4e:��Owner/Contra r Signature Date