06080024 CITY OF CUPERTINO
`ft FURNACE/AC
UPERTINO PERMIT APPLICATION FORM
APN# �j'I j1 /��l Date:
Building Address:(L J
00 9a
Owner's Name: 1 Phone #:
�ae: O 1J K �,� 053 o1b13
Contrac Phone: License#:
�ecrzc a� 2 40Cs-�c�1 9SS/s 3-315-Fr
Contac : Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect D�- Plumb Mech
Job Descripti n: / Q
Q �kkerace a ✓lo A L 4-d hl(me.
Residential Commercial ❑
For Residential Inst ations:
Attic ❑ l' floor 22nd floor❑
Adhere to min set back requirement p�
or Commercial Installations:
Replacement same weight ❑ Additional weight(structural cales) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required
Cost of Proj ct: Type of Construction: Occupancy group:
Strapped 0 On Platform BondedZ Sq.Ft. Floor Area:
New Location Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units<= 10, 000 cfm MECHANICAL
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
qWF BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BPGAS Gas Piping System Fee PLUMBING
BUSLIC Business License BUILDING
CITY OF CUPERTINO +T
BUILDING DIVISION PERMIT UNTRACTORANk.�ORMATdv10
BUILDING ADDRESS: A PERFECT CLIMATE PEBMrrnO.06080024
10092 FIRWOOD DR
OW NER'S NAME: PERMIT ISSUE DATE
ASHAUTOSH DIKSHIT 10570 S DE
NE: SANITARY NO. CONTROL NO.
(408) 86119545
ARCHITECVENGINEER: U ING PERM RINFO
PLUMB MEOCH
ME LICENSED CONTRACTOR'S DECLARATION as
1 Mreby affirm that I em licensed under provisions of Chapter 9(commencing Job Description •-
.10 Sheilah 7000).f Division 3 afNe Bmi.sual Rofessions Cade,and my license is nOCIM//
>� in full to=and effeal./( at'�/� a 31 S B REPLACE FURNACE ADD ,A/C
; ? License Clw�y Cmam _ //lT� I :l'yC
T 7Wp Dak 2tii-' YY• O gh� CSDECr �I rad \.M e, Doi, l:/
AR 0.1TECTS DECLARATION
i < I undersand my Plans Nall he used u public records
d
-G G Licensed Professional
OWNER-BUILDER DECLARATION
i I hamhy affirm
that 1 exempt from the ConuanmH License taw for the
o O following moron.(Section 71D 1.1.5,Bmincaa and hvfauiau Cada:Any city tar county
$ which mquims a permit re consu eL alter,Improve,demolish,or repair my mmctum 7 5 8 3
Prior m its issuance,also requires the applkul forsuch permit to lite a signed comment
personal< that he is licensed personal m the previslmm of the Conuhcter'sLame law chapter Sq.Ft.Floor Area Valuation
$ (commencing with Senlon7000)of DivWm%3af Ne Bminessand Profeulaa Crec)or
that he is exempt Werefmm snd Out but,for the alleged assumption.Any violatan of
Section 7031.3 by any applicant far a permit subjects the Applicant to a civil Funny of Occupancy Type
hat mare than Ree huadrtd dollars(5300).
I,as murmurer Ne property,an my employes whh wags u Nab golecompensaton,
will do the wank and the atmmum Is not kunded or offered for rude(sec.7044,BusinessRe aired Inspections
and Professm kCade The Comamusn s Warne LAW does set apply 0 an owner of q P
property who builds m improves Thermo,and who alas such work himsel f or through his
ownemployma.pruWkd Nal such impmvemenu rte rmtimmndedarartemd fasak.IL
however,the buildinger Improwmant is gold within am you of completion.Ne owner-
builder will Mw One coram of pmving that he did not build or Improve for purpose of
sale.).
❑1,as matter of Ne property sun eaelusiwly cantocting with licensed com anon to
caesmct use project(See.7044.Business arm Professions Cade)lie Contractors Li. .
causes Law does not apply to me owner a property who build or hnprows thereon.and,
who come cu for such pmje=with a contrauor(s)licensed punmm an the Conuacmts
Lice.law.
❑laaaemptarderSea ,B&PCfartMareuon
Owner Dam
WORKERS COMPENSATION DECLARATION
I hereby aflim under parody of perjury am of the following declaruioluc
1 Mw and will mdntala a Certificate of Comment mself-insure for WaftesCompm-
ation.u provided for by Salon 3700 of Ih tabor Cade,far,Nc pedamma of tie
work for which this permit is issued.
❑1 haw and will maintain Worker's Compenmtian Insurance,as required by Section
3700 of the Labor Code,for the performance of But work forwMch this permit Is!ahead.
My Worker's Com,,��e�ruIt Imunnce artier and Policy number are:
Carder->�) J�qT( PolicyNo.: k Ll85NO01 �jSa 0`?0 50 0
CEERTIFICATE OF EXEMPnON FROM WORKERS'
44Ctt 4f 19--4 COMPENSATION INSURANCE
(Thlasealon need set wcompked Bthe pemil k room hunthW dmBan(5100)
of less.)
1 certify that In the performance of tho work fa which Nis permit is issued.l shall has
employ anypergon in any manrcrse as to become subject W the Workere Compensation
Lam of Coltrane.Data
Applicant
NOTICE TO APPLICANT:IC after making this CeniOcam of Exemption,you almubl
become subject he the Workers Compensation previsions of she labor Cada,you mum
Q 0 flarNwh comply with mesh pmviskm a Nu permit Nall be deemed revoked.
,Z,a CONSTRUCTION LENDING AGENCY
y
[-. 1 hereby a firm that tem is a conswrion loading agency for tic Performance of
CL> the work for which this permit Is issued(Sec.3097.Civ.C.)
QW.Q Landels Name
Q z Lender's Address
V Q 1 aNfy them I have read this application am sum that the above information is
ty H correct.I agree m comply with all city and county ardinames and auto laws relating to
Q V building construction,and hereby mahome mpresenativra of this city to enter upon the
W albve-mentioned property for inspection purposes.
gy (We)agme to nor,too...ify and kap harmless One City of Cuperom against
5r liabilities.judgments.career and expenses which may in my way sccrm agaiml said Gly
,x in eomcgeame of the¬ing of this permit.
^� APPL ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date L( as�+
S U 9 REGULATIONS. Re-roofs
Signature of ApplianUConumtur Dale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or(anon building occupant seam or handle mention material
as;denned by Ne Cupertino Municipal Cade.Chapter 9.13,aha to Health and Safety
Cale,Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will to applicant or future wilding occupant nae equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
tail sometimes air anmminenu u dented by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Nu
I hew mad the haurdmssmamrlalsmquimmenu underChapmr 6.95 of NeCali(or-
n1.Hcahh&SaretyCode,Sectam25SU5,25533md25534.1undcmmdNeif Ne wilding
alas not umntM
ly w s mnan4 at It' m respoulldllly m notify de acupmt of Ne
myt)!re ch�pmelbe etpmar trace of a ccnincam of° upon�y. Signature of Applicant Date
�j �"f� " !y o All roof coverings to be Class"B"or better
Ower or authorised agent Date"
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
OUPE�TINO
Building Department
JOB ADDRESS: PERMIT #
ooaa r(nwOed 0( E-QD
OWNER'S NAME: Al, a L,4 0. (J' t111' PHONE # Vim- k 01 . 95-
GENERAL
SGENERAL CONTRACTORec e—r, m of e FAX #
I am not using any subcontractors:
ikamw-
Signature IDate
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
�m 1 of 3 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 34233037 . 00
DATE ISSUED. . . . . . . : 08/04/2006
RECEIPT # . . . . . . . . . : 35513
REFERENCE ID # . . . : 06080024
SITE ADDRESS . . . . . : 10092 FIRWOOD DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : ASHAUTOSH DIKSHIT
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : A PERFECT CLIMATE
CONTRACTOR . . . . . . . : SMITH, BYRON E LIC # 21144
COMPANY . . . . . . . . . . : A PERFECT CLIMATE
ADDRESS . . . . . . . . . . : 10570 S DEANZA BLVD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE (408) 86119545
WEE 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
BREMRECEPT NO. OUTLETS 1 . 00 1 . 20 0 . 00 1 . 20 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
BSEISMICRE VALUATION 7, 583 . 00 0 . 80 0 . 00 0 . 80 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 176 . 54 0 . 00 176 . 54 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL