11110082 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21836 WOODBURY DR CONTRACTOR:ALLIED AIRE PERMIT NO: 11110082
SERVICE INC
OWNER'S NAME: CHEN SAMUEL C AND THERESA K 470 S HILLVIEW DR DATE ISSUED: 11/15/2011
7c1h."11
NER'S PHONE: 4082522555 MILPITAS, CA 95035 PHONE NO:(408)934-8844
LICENSED CONTRACTOR'S DECLARATION r. r r
/� ^ _ BUILDING PERMIT INFO: BLDG ELECT PLUMBnseClassGi010,38 Lic.N ;,GC103 �AAMECH r RESIDENTIAL r COMMERCIAL rmctor/�.U.-1 C /•Itl IZG Date 1I S 1 JOB DESCRIPTION:REPLACE FURNACE IN ATTIC AND ADD A/C
reby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full farce and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
1 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 whichthis permit is issued. Sq.Ft Floor Area: Valuation:$5800
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 APN Number:32619070.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of flu it. di ition y,the gtplicant understands and will comply Issued by Date:
with all nor, tat our he Cupertino Municipal Code,Section
9.18.
1 l �jl RE-ROOFS:
Signature Dale All roofs shall be inspected prior to any roofing material berg installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Low for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,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&Professions Code) '
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(x)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as dented by the Bay Area Air Quality Management District 1
performance of the work for which this permit is issued. will maintain compliance with a Cupe ino ' al Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,S in s 2 ,25 ,end 2 4.
Section 3700 of the Labor Code,for die performance of the work for which this Owner or authorized age : Date:
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person many manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm this there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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
to building construction,and hereby authorize representatives of this city to enter
on the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
mnify and keep harmless the City of Cupertino against liabilities,judgments,
,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
noting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
. 7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: bethe
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 32619070 . 00
DATE ISSUED. . . . . . . : 11/15/2011
RECEIPT #. . . . . . . . . : BS000015320
REFERENCE ID # . . . : 11110082
SITE ADDRESS . . . . . : 21836 WOODBURY DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : CHEN SAMUEL C AND THERESA K
ADDRESS . . . . . . . . . . : 21836 WODBURY DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1148
RECEIVED FROM . . . . . : ALLIED AIRE
CONTRACTOR . . . . . . . : STEINER, ARNOLD R LIC # 19207
COMPANY . . . . . . . . . . : ALLIED AIRE SERVICE INC
ADDRESS . . . . . . . . . . : 470 S HILLVIEW DR
CITY/STATE/ZIP . . . : MILPITAS, CA 95035
TELEPHONE . . . . . . . . : (408) 934-8844
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS 1 . 00 41 . 00 0 . 00 41 . 00 0 . 00
1BCBSC VALUATION 5, 800 . 00 1 . 00 0 . 00 1 .00 0 . 00
1BREMAIRHA NO.UNITS 1 . 00 65 . 00 0 . 00 65 . 00 0 . 00
1BSEISMICR VALUATION 5, 800 . 00 0 . 58 0 . 00 0 . 58 0 . 00
1MFR=<100 UNITS 1 . 00 130 . 00 0 .00 130 . 00 0 . 00
1MPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00
1TRAVDOC FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 325 . 58 0 . 00 325 .58 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
- ----------------- --------------- --------------------
CHECK 325 .58 22637
---------------
TOTAL RECEIPT 325 .58
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
U P E RT I N O Telephone: 408-777-3228
Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: RY k • PERMIT#
OWNER'S NAME: e* EN. PHONE#
GENERAL CONTRACTOR: Q 1c S tyL- BUSINESS LICENSE#
ADDRESS: 470 S. h..LVIEtJ A . CITY/ZIPCODE: Its TI14S CA Q 03S
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OC UPA CV I SPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND AL . SR CTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
1 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
Al Fencing
Flooring/ Carpeting
Linoleum/ Wood
Glass/Glazing �7
Heating t.I.IGD ktae Set .
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
tile
II IIS � 'otl
Owner/Contractor Signature Date
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 � '
sc
.CUPERTINO (408)777-3228• FAX(408)777-3333• buildinaCcbcuoer no.orcl rr11
PLUMBIIrNG MECHANICAL ELECTRICAL �/ MISOMLANEOUS DOVE
PAo7ECC ADDRESS I. 3�O R AIN*
/Q
-o-7O
OWNER NAME E-MAIL_jq ` ' rSg
SIAEEIAD➢RESS
0 /� FAX
CONTACT NAME PHONE 1. E-MAR/
STREETADDR03 CITY,STATE, ZIP FAX
❑DWNEE ❑ OWNER.aunDER ❑ OWNERACENf QIMNACttIR ❑CONTRACrQRAOFNT ❑ ARamECT ❑ENCBIEFJI ❑ DEVELOPER ❑TENANT
CONTRACTOR! IICENSB Ox)�S L" � j3 BUS,LICA
COMPANY NAME ' E-MAIL FAX
I�.I�=� taa Srx- ,A
STAEETADDRESS ,i✓• 7+. I/`�vsly ��(— CrrY ,i�AITI� S
ARCHITECDENOINEER NAME Ft LICENSE NUMBER BUS.LC p
COMPANYNAME' E-MAIL FAX
fINO:
ADDRESS CITY,STATE.ZIP PHONE
SFO m DUPLEX ❑ MULTI-FAMILY P0.0fEGT DI WDALVm ❑ YESPROTECT 87 ❑YES DTHE BLOC AN ❑YES
❑COMIMERCIAL URBAN INTERFACE ARP. ❑ NO FLOOD ZONE ❑NO ECH ER HOME? ❑NO
RION OP WOAK EP�.�rcC I2�kGE I Ar •L +
TOTAL VALUATION: 5$ f — RECETVEO BY:
Hy my signature below,I certify m ch f tha fe g: I son the property owner or authorized agent m act an the property owner's behalf I have read this
application aad the information I ve vide a tvd the Dwcripdon of Work and verify it is accurate. I agree m comply with all applicable local
oNmances and smm laws relator m 'ding anth entatives of Cupertino m anter the above-identifi rraperry for bupection Put�tases.
Signetme of Applicant(AgrntY Date: T i sCN D I I
SUPPLEMENTAL INFORMATION REQUaW OFFI sE ONLY
W OVER-THE-COUNTER
s
❑ EXPRESS
Y
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sc ❑ STANDARD
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❑ URGE
4.
❑ MAJOR
MPPMcrcdpp 2011.doc revised 0621/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
. ADDRESS: 21836 Woodbury Dr. DATE: 11/15/2011 REVIEWED BY: jag
APN: BP#: "VALUATION: $5,800
"PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: PERMIT TYPE:
WORK a lace attic furnace and add AC
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $130
A/C Units (<=1 OK cfm) 1BREMAIR 1 # $65
TOTALS: $195.00
Mech.Plan Check 0.0 hrs $0.00 Phu„b
.Plan i"hank liter.•.1'!m,(,."hceti-
Mech.Permit Fee: I MPERMIT mun;t>. Pernvl F<:c: FrIbc. Permit Fee:
Other Mech.Insp. 0.0 hrs $44.00 Other Ph..ib hup. Other£lee. b»p. El
,14e,h.Imp, Fee: Pluwb. bur"J-ve frier.Imp. Pce:
NOTE: This estimate does not Include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the prefinina In ormation available and are only an estimate. Contact the Dept for addn'l Info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/11) FEE QTY/FEE MISC ITEMS
Flan Check 1,cc:
Suppl. F'('F'ce
PME Plan Check: $0.00
P¢rntit/%ce:
Suppl. hasp Fee
PME Unit Fee: $195.00
PME Permit Fee: $44.00
( on•structiun Tac
Administrative Fee: ]ADMIN $41.00
Work Without Permit? Yes (E) No $0.00
i,lrarnced Planrning Fees:
Travel Documentation Fee: ITRAVDOC $44.00
Shone Motion Fee: JBSE1SM/CR $0.58 Select an Administrative Item
• Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $325.58 $0.00 TOTAL FEE: $325.58
Revised: 10/01/2011