08100209 CITY OF CUPERTINO ef' '
BUILDING DIVISION PERMIT CU P$TRACTORI1 ',U'.RNTA�TI1�F
BUILDING ADDRESS: PERMR NO.
1 242
OWNER'S NAME: PERMIT ISSUE DATE
SA CONTROL NO.
p .
ARCHTIER(ENGINEER:
BUILDING PERMIT INFO
-� -BLDG ELECT PLUMB MECH
INSTALL FORCED AIR FURNACE p O O O
'COQ LICENSED CONTRACTOR'S DECLARATION
r�« 1 hereby affirm than 1 has lianas under provisions of Chaps«9(mmmen ims Job Description
with Section TM)Of Division 7 of the Business and Profuduns Conn.W my lief.is
in full fora aM cO
z- License Class_
Dam Con LLT4^ '�As�-efARCHITECTS
ARCHITECTS DECLARATION
s
U 1 undentaml my plans shall W used a public mcorm .
O in Licenced Professions
Oat I am exempt
from
DECLARATION
Conu no
nyny 1 hereby
affirm mel 1 1. exempt from the Crdons o :Any c Lew for IW:
`p o fallowing rosson.(Salon 11171.5 Business and Refusions Cade:Any city or county -
Rsff which requvu+permit no corns alcor.improve, ler mash suuctum
prior In,its issuance.alsa mquitoss the applicant farsuch permit to file a ed
E
that
uncrei gwithSudan7 me proviviomofmcCanuinesaniartselsion;Co tag Sq.F[. Floor Area Valuation
rci $ (conmcncing with Section 7000)of Division J of IW Business and Professions Cade)or
s that he is mumps mounfrom and the hasu f«the alleged exemption.Any violation of
Section 7071.3 by any applicant four+permit subjects the aPPlicam m a Civil Porosity a APN Number Occupancy Type
rot moa dun flew hmdned dollars($500).
❑1,as owau of IW property,or my wplay.with wages as their ham eampenadon,
will do the work,and eve shomem B act intended«offers for ale(Sec.7066.Business
and prognathous Cade:Tic Camerons License Law ma ant appy to an owner M Required Inspections
paputy who Wilds«improvesmveran and who docasuchwerkhimself«through his
own employees,provided thstach improvements am rot inched«oRaet(orale U.
hmamna.the building«imposemat Wsold within as year of Compledon,the ownsr-
builder w01 bow dm burden of poring mat k did not Wild or Improve f«purpose of
ale.).
t]1.as aw o,of the pmpny am cammu ly contracting vim sussed tmntracrms m
Conswn she project(sec 70ad,Businu,am Professions Code:)The Covuasms U, _
cue Law does mat apply as m awn«W MPMY who Wilda or impmow daemon.ens.
who contracts for such projects with a commater(s)licensed purauam m the Conuclors
License Law.
tarn exempt mom,See ,B k P C for then tia,oa
Ow«s Dae
WORKER'S COMPENSATION DECLARATION
I beneby affirm under Penalty of perjury oro of ft fallowing decWadmme
I have and will maintain a CarthOcale of Consent I. f«Workers Compmn ,
'on,as provided for by Section 7700 of do Labor Code,for me performance of me
wort:for which mu Permit is issued.
❑I haw and will maintain Workers Compensation lasmana,as required by Section
7700 ofineLab«Code,for me performance ofine wart for which dais permit is issued. '
My Workers Campeaation Nsuana aria and Policy number+m:
Carrier. Policy No.:
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Cltds Galan need mot W completed Ifft Permit is furan handmddoltaa($100)
or less)
1 certify mat in the Performance of me work for which mis Permit is issued.1 shill sot
employ any penan in any manner an m m become subject to the Worker'Compensation
Isws of Calirwrd Dau
AppBcant Xlf f
NOGCE TO APP :If.rs arum making this Certificate of Eaemptiom,you u aum
.,Obccmne b Comp m the Workers Coons ne Compensation provisions of me Isb«Cole.vats must
fanhwith amply with such provisions«coif Peanit shall W deenpa rewkN. '
Z CA CONSTRUCTION LENDING AGENCY
�� do wort rte WhalBu NU Nene is a counteraction lendingageocy for the performance of
Permit is issued(Ser.7097,Civ.C.)
GQ L caders Name ,
Z)z Lawes Admen
U C) 1 .Ofy that 1 have Orsi this applieaion and sum dust do+hove infomu i.B
Iy E•' cones.I agree to comply with all city and County ordinances and Stale lawn malting an
.0 U Wilding construction,and bemby aum«im rpommom s of mu city to emmrapn the
w above-mentioned property for inspection punPOmL
6. (We)Agree to ave,indemnify and kap harmless the City of Cupertino against
rFi ti
liabilities.judgments,costs and expenses which may in Cly way aaac against said City
U 2 in conseq«sce of me granting of this Permit. �7
^+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S�O/{51Is�yER�EGU[.ATIJONS.
V Vk.�lt,g.aii _ 10"-311O?Fy Re-roofs '
Signature of AMImMUContracmor Data -
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ar future Wilding aceupanL stare«handle havudou material
a deftecd by the Cup-dam Municipal Cam.Chapter 9.11.and alp Health and Safety
Code.secmm 25532(+)7 All roofs shall be inspected prior to any roofing material being installed.
r]Y. TO
Will me applicant or future Wilding Occupant as equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
j4kPit hsysdous air contaminants as dcrined by the Bay Area Air Quadm
ity Management all new materials for inspection.
aricm7
❑Yo INNu
1 have mal the ha»wwarnaeriatsnequimments under Chapter 495 of the Calif«-
niaHulthASafayCodc.Seedam15N5.15577and25534.1undvawdmatifmc Wilding
does Opt Cunrand,haw+vaam that it ts my resptwiWlity m miry the nccefoom of me
Mae,which moa W met prior m iavarce of a Catifpam of aapan .. Signature of Applicant Date
n 1� C ( r)--A I—c�i� All roof coverings to be Class'%"or better
Owner«mmarrcd agent Dam
CITY OF CUPERTINO
• 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN 32630012 . 00
DATE ISSUED. . . . . . . : 10/31/2008
RECEIPT # . . . . . . . . . : BS000006522
REFERENCE ID # . . . : 08100209
SITE ADDRESS . . . . . : 10242 N STELLING RD.
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : MAHENDRA KUMAR
ADDRESS . . . . . . . . . . : 10242 N STELLING RD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : NORTHCAL HEATING
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE . . . . . . . . :
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ----- ------- -------- ------- ---------- ----------
1BSEISMICR VALUATION 5, 300 . 00 0 . 60 0 . 00 0 . 60 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 224 . 95 0 . 00 224 . 95 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- ---- ---------
CHECK 224. 95 129
---------------
TOTAL RECEIPT 224. 95
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ------ ----------- -------- ----------------------------
505
--- ------ ----
505 FINAL ELECTRICAL 507 - FINAL PLUMBING
508 FINAL MECHANICAL
Community Development
v 10300 Torre Avenue
r Cupertino CA 95014
Telephone(408)777-3228
CITY Of Fax(408)777-3333
*UPERTINO
Building De artment
JOB ADDRESS: PERMIT #
102 2 Aj. S4e11 oe/ m2nr
OWNER'S NAME: t�AAwxPHONE —/Oo
GENERAL CONTRACTOR-,V p "t FAX #
I am not using any subcontractors: )c9-3 I — O cid
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
I_�3 ► -0 'P
Owner/Contractor Signature Date
CITY OF CUPERTINO
FURNACE/AC
0CUPERl OF
TINO PERMIT APPLICATION FORM
. b8I6UZa °I.
APN# � Date:
LlP CJ 2,DO
Building Address:
)0242 tV. S4eLL1&, 4,20
Owner's Name: Phone#:
�--lqMAr!�L- AlfJ o�F 725-10o6
Contractor: Phone#: 4.-f3 SS
0ES7r+4 CAL 44-t� 1T'1 A o 4-1 Fax #: 6 f6 9 52 � mj
Contractor License #: I ' Cupertino Business License#:
Contact: Phone#: Cr,
Fax #:
Building Permit Info:
Elect ECT/ Plumb Mech
Residential Commercial
ob Description: Fp2Ci9j A112 y NDN E
e lv �a OLV
For Residential Installations:
Attic ® 151 floor ❑ 2nd floor ❑
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 ❑
Cost of Project: S��r Type of Construction (Usage Class):
V[3
Strapped On Platform El Bonded ❑ New Location ❑ Replacement
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/ACC1 OF
,
CUPERTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
FURNACE FURN/AC
1MCRAA Commercial-Repair/Alteration/Add to M
ea heating appliance,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,absorption or
evaporative cooling system,incl
installation of controls regulated by this
code.
IMCREPALT Commercial for the repair of alt/add to M
ea heating appliance,refrigeration
unit,cooling unit,VAV boxes,
absorption unit or ea heathing, cooling
absorption,or evaporative cooling sys,
incl install of controls regulated by
this code.
1MCSUSHTR Commercial Install/Relocate ea M
suspended heater,recessed wall htr, or •
floor mounted unit heater.
1PGASCOM Commerical for ea gas piping System P
1-4 outlets
1BPGAS For each gas piping system of 5 or P
more per outlet.
1MCAPPVNT Commercial for the install/relocate/ or M
replacement of ea appliance vent
installed ¬ incl in an appliance
permit.
113SEISMICO Commercial Seismic B
1MRRAA Residential Repair/Alteration/Add to M
ea heating appliance,refrigeration unit,
cooling unit,absorption unit,or ea
(/ heating,cooling,absorption or
evaporative cooling system,incl
installation of controls regulated by
this code.
1MRSUSHTR Residential Install/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted unit heater.
1 MRAPPVNT Residential for the install/relocate/or M •
replacement of ea appliance vent
install & not incl in an appl pennit.
Quantity Fee ID Fee Description Fee Permit Type
Groun