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12010039 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 11187 LINDA VISTA DR CONTRACTOR:SANDIUM PERMIT NO: 12010039 OWNER'S NAME: CHU YEN AND JANE TRUSTEE 4223 VERDIGRIS CIR DATE ISSUED:01/05/2012 OWNER'S PHONE: 4082578461 SAN JOSE,CA 95134 PHONE NO:(408)894-9072 Ld' LICENSED CONTRACTOR'S DECLARATIONF_ � gB$�bel BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class ZQ Lic.# S MECH RESIDENTIAL COMMERCIAL n�o *� ` r � Date t I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:FURNACE AND DUCT REPLACEMENT (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'$8500 1 have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the perfonnance of the work for which this permit is issued. APN Number:35626022.00 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 permit. Additionally,the applicant understands and will comply y with all non-point source regulations per the Cupertino Municipal Code,SectionIssued by: Date• 9.18. Signature ,, —Date J l Z 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: I,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 by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&Safety Code,Sections 25505,25533,and 25534. I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Worker's O or author' gent: Compensation laws of California. If,after making this certificate of exemption,I e JA_e 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 upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35626022.00 DATE ISSUED. . . . . . . : 01/05/2012 RECEIPT #. . . . . . . . . BS000015675 REFERENCE ID # . . . : 12010039 SITE ADDRESS . . . . . : 11187 LINDA VISTA DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : CHU YEN AND JANE TRUSTEE ADDRESS . . . . . . . . . . : 11187 LINDA VISTA CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4754 RECEIVED FROM . . . . : YIU-HANG LEE CONTRACTOR . . . . . . . : MICHAEL LEE LIC # 28867 COMPANY . . . . . . . . . . . SANDIUM ADDRESS . . . . . . . . . . : 4223 VERDIGRIS CIR CITY/STATE/ZIP . . . : SAN JOSE, CA 95134 TELEPHONE . . . . . . . . : (408) 894-9072 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 8, 500 . 00 1. 00 0. 00 1 .00 0. 00 1BSEISMICR VALUATION 8, 500 . 00 0.85 0. 00 0 .85 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 1MRRAA UNITS 1. 00 65. 00 0.00 65 .00 0. 00 1TRAVDOC FLAT RATE 1. 00 44 .00 0. 00 44 .00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 325.85 0. 00 325.85 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 325.85 VISA --------------- TOTAL RECEIPT 325.85 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 11187 linda vista DATE: 01/05/2012 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$8,500 ;PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Du lex PENTAMATION FURN/AC USE: p PERMIT TYPE: WORK furnace and duct replacement SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Furnace, Forced-Air 1MFR=<100 1 # $130 Heating System 1 MRRAA 1 # $65 TOTALS: $195.00 Mech.Plan Check "00 $0.00 Mech.Permit Fee: I MPERMIT - Other Mech.Insp. 0.0 hrs $44.00 0 NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). Theseees are based on the relinina information available and are onl an estimate. Contact the De t or addn'l in o. FEE ITEMS fl-'ee Resolution I1-053 Eff jjjj FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $195.00 PME Permit Fee: $44.00 Administrative Fee: (ADMIN $41.00 Work Without Permit? Yes (D No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 A Stron<,),Motion Fee: IBSEISMICR $0.85 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $325.85 $0.00 TOTAL FEE: $325.85 Revised: 1/01/2012 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: WI S 7 PERMIT# I OWNER'S NAME: rL PHONE# 4 ZS 7 4-b � GENERAL CONTRACTOR: t BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum /Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock E:] Tile Owner/Contractor Signature Date GENERAL PERMIT APPLICATION MEP 2 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228•FAX(408)777-3333• building(aDcupertino.org MISIC CUPERTINO PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS I _� i `'rte AP� r �r 0 OWNER NAME g C` PHONE 4A '15; [ M`rf ( E-MAII. STREET ADDRESS � � " CITY, STATE,ZIP FAX �'ut-mac- Cvo e✓� CONTACT NAME PHONE E-MAII 5 - 0-4 „a STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUIIAEP ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME �� l�� LICENSE NU1yfB� 1 LICENSE ZEA BUS.LIC# COMPANY NAME (/ E-MAIL FAX STREET ADDRESS CITY,STAEIPHONE YZ3 qJ,3(-� ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF FD or DUPLEX ❑ MULTI-FAMII.Y PROJECT IN WIIALAND ❑ YESPROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: 13 COMMERCIAL URBAN INTERFACE AREA ❑ NO FFLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK TOTAL VALUATION: RECEIVED BY: S By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. i have read the Description of Work and verify it is accurate. I agree to C?Wply with all applicable local ordinances and state laws relating to buil struction`I authorize representatives of Cupertino to enter the above-ideintifi d {�`tv for inspection pu#poses. Signature of Applicant/Agent Date: L l W/ (?- SUPPLEMENTAL INFORMATION REQUI.ItED � O�FFICE USE ONLY IZI.OVER-THE-COUNTER c ❑ EXPRESS Y U _T ❑ STANDARD V ❑ LARGE ❑ MAJOR MEPMiscApp_2011.doc revised 06121111