05060119 -CITY OF CUPERTINO
BUILDING DIVISIONPERMITR, INFORMATION
BUILDING ADDRESS: AIR QUALITY HEATING & AIRC M'TNO05060119
21008 HAZELBROOK DR
1111 NAME: PERMIT ISSUEDATE
GEORGE CHEN & CINDY CHAN 714 NORTHRUP ST 06/17/2005
PHONE: SANITARY NO. CONTROL NO.
(408) 293-7138
ARCHITECT/ENGINEER: BUIWING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�Oo LICENSED CONTRACTOR'S DECLARATION
c G I herby affi
rm that 1 am licensed under provisions of Chapter 9(commencing Job Description
�� with Scuion7lNttq of Division 3afuc Business and Professions Codaandmyliccascis
R in full '��q y� INSTALL 2 A/C UNITS
j,Ovj�_ License,Clan Q 'a _.j1i4
�Fp Date h—/�Canuacwr A�, Frt�tt f� It e
O y U ARCHITECTS DECLARATION rE®
Vy w< 1 undcmanJ my plain shall W recd u DpudliC recordsECLARATION
U J�; I ILII/ t1'`S
G Lkcnsed Pmfcssional
g OWNER-BUILDER DECLARATION / /
4<y I Wmby anion Nm 1 am exempt from ibe Contractors License Law for the 6 6/�31 A1/♦1,
00 following nuam.(Section 70211.5.Beat.and Pwfessiun Cale:Any city ar rnnot,
�Ul'�
,a m�+ which mquiru a Permit ser emmandeL after,urroom.dcmulLah,or.pair any strvcmr ,� "85500
yii prior w ie issuance.also requires rW applicam for such permit to rile a signed statement
s that he is licensed pursuant to Ne prevision of the Comncwr's Limn,law(Chapter 9 Sq.Ft. Floor Area r� j (q�`Valuation//��
Y_G
(commencing with Section 7000)a(Division]of the Business and Profession Code)or .1I)I�\ttry �a
that M is exempt dumafwm and the beau for the alleged exemption.Any violani of
U sir LJJ ) I'11 Lir
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of ar Occupancy Ty'pe
not mart than In hundred della.(S50(y.
1,n owner of the property.Or my employees wit wages n their win compereadon,
will do be work,and the structure is not intended or offered for one(Sec.7064.Business
and Professions Code:The Contmcwrs License Law don Out apply to an owner of Required Inspections
property who builds or barrows theman,and who docssuch work himselfor trough his
own employees,provided that such improvements are not intended oroRered for sale.If,
however,the building or improvement is sob within one year of complcdon,the owner. _
builder will have the burden of proving that he did not Wild or improv for purpose of
sal..).
1,as owner of the progeny,am exclusively contracting with licensed contractors to
construct to pnjecl(Sec.]IML.Business and Prafeuion Code:)The Conuacwrs Li
Genu law does not apply w an owner of property who Wilds or imposes demon.and
who contracts for such projects wit a eonuacwr(s)licensed pursuant o the Contractors
License law.
❑ I am exempt under Sea .B A P C for this pawn
Or Dale
WORKER'S COMPENSATION DECLARATION
1 herby from under penult,of perjury oro of the following declarations:
O I ham and will maintain a Ccooliinm of Cnrem to self-insum for Worker's Compere
cation,u provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
D 1 have and will maintain Workers Compensation Insurance,as required by Section
37M of tc Labor Code,far the performance of to work for which this permit is issued.
My Wofkef'sC/n�npen}wtion In/su�anee ci1rticr and Policy ranter
am: L./
Carrier. �T-a/ �. r' ; Policy No.:�L—2
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the permit is furan,hundred dollars(SIM)
or Let.)
1 certify that in the performance of dm work for which this Permit is issued.I shall nor
employ any peon in any manner,w u to became subject la the Wafkeri Compenwdan
Iawsof California.Date
Applicant
NOTICE TO APPLICANT:If,after making Nis Ccniricale of Exemption,you should
become subject m the Worker's Compensation provisions of the labor Cmdc,you mus
w,Z foMwit comply wit such provision or this permit shall W deemed rewked.
Z O CONSTRUCTION LENDING AGENCY
[-+� I hereby ofrom tar tart is a conuuctinn lending agency lot the performance of
G' the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Leadcr's Name
=z Lender's Address
U p 1 certify tat 1 have read this application and sum that the show information is
U. F correct.1 agree to comply with all city and county ordinances and sure laws miming to
0 U building construction.and hereby authorise representatives of this City to enter upon the
r W show emitted nropeny foriospection purposes.
(We)agree to cave,itolerant,and keep harmless the City of Cupertino against
F" f�jl liabilities,judgments,costs and expenses which may in any way accrue againstcu City .
U lin consequence of the granting of this permit.
^' APPLICANT UNDE STAND ND ILL COMPLY WITH ALL NON-POINT Issued by: Date
r SOURCE U ONS.
�/7-ORe-roofs
Sign cef ApplicamVConr.cwr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
W
Will to applicant or town Wilding occupant tore or handle havallon material
as defined by Irk Cupertino Municipal Code.Copier 9.12,and the Health and Safety
.seeder 25532(a)7
0 All roofs shall be inspected prior to any roofing material being installed.
Will to applicant Or future building Occupant and equipment or dcvicn which If a roof is installed without first obtaining an inspection,I agree to remove
,mil hd/afdllaa air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
Yes
I have mad the haraod mts_materials requirements under Chapter 6.95 of the Califor.
nia Hurt S SafelyCalc,Sccdon 25505,25533 and 25534.1 undersand that ifte building
does no,currcndy have a lessor,that it is my responsibility w notify rW acUPnl of th,
mquiremcnu wE I(mostter ssuaucc of a Ccrilicaw of acup=y. Si re of Applicant Date
—/7-1"Jf All roof coverings to be Class"B"or better
Q cr or.tolmn.d agent Date
CITY OF CUPERTINO
� - FURNACE/AC
�PEkTINO PERMIT APPLICATION FORM
D/a-te:
APN # 32C sso 3 7 ll��l ��
Building Address:
Z vs k r�
O 's Name: Phone #:
er
Mr Clv ¢ C1nah 06' g13 :1-161 Z
Contract&: Phone: License#:
Contact: Phone: Cupertino Business License#:
A�Aq'G J I irJac✓ `�a 25� 7�3�
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech
Job Description:
I1 (2-) A-i-r Cnd, 1ioiivzun k 3 - V,-7 eXCG,.
Residential ER Commercial ❑
For Residential Installations:
Attic ❑ I't floor ❑ 2"d floor❑
here to min set back requirement (
Mr Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: vo Type of Construction: Occupancy group:
5,3-co. —1i
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
_ BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cf-n MECHANICAL
Z BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
- BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License L.PUILDING
• CITY OF CUPERTINO
Item 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp: Rng : Sub: Blk: Lot :
APN . . . . . . . . : 32655037 . 00
DATE ISSUED. . . . . . . : 06/17/2005
RECEIPT # . . . . . . . . . : 30022
REFERENCE ID # . . . : 05060119
SITE ADDRESS . . . . . : 21008 HAZELBROOK DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . :
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : GEORGE CHEN & CINDY CHAN
ADDRESS . . . . . . . . . . : 21008 HAZELBROOK DR
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : MATTHEW FARBER
CONTRACTOR . . . . . . . : MATTHEW FARBER LIC # 22791
COMPANY . . . . . . . . . . : AIR QUALITY HEATING & AIRCON
ADDRESS . . . . . . . . . . : 714 NORTHRUP ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95128
TELEPHONE . . . . . . . . : (408) 293-7138
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
-- ------------- ---- ---- -- ----- --------- -
BREMAIRHAN NO.UNITS 2 . 00 20 . 52 0 . 00 20 . 52 0 . 00
BENERGY PERMIT FEE 1 . 00 34 . 86 0 . 00 34 . 86 0 . 00
BREMRECEPT NO. OUTLETS 2 . 00 2 .40 0 . 00 2 . 40 0 . 00
MPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
BSEISMICRE VALUATION 5, 500 . 00 0 . 60 0 . 00 0 . 60 0 . 00
EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
TOTAL PERMIT 135 . 12 0 . 00 135 . 12 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- -------- - --- ---- - - - - --
OTHER 135 . 12 M/C
TOTAL RECEIPT 135 . 12
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
---------------------------- ________ __________----------________
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY
502 FINAL PLUMBING ENERGY 503 FINAL MECHANICAL ENERGY
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
•
APPROVED
jN ACCORDANCE WITH
......------..- -JHE,CITY-0i-.--,..-
PLOT PLANS CUPERTINO CODES AND ORDINANCES
os—
QATWK 7/
[his stetof pans zend specifications MUS'
—Md ')a kept nn-jhe-job-at-aiLt4m&aFA-it4s-tt,,
lawful to make any changes or alteration
in same without written—permissic, "I,
lie building Dept., City of Cupertino.
"he stamping of this P r1firgdon.
�HALL NOT be heid to permit or to be ai
)Qroval of the violation of any ur 0,
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JUN 1 7 005
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