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12010107 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22017 IMC CLELLAN RD CONTRACTOR PERMIT NO: 12010107 OWNER'S NAME: ISLAM SYED AND ALI SADEKA S I t� /��? DATE ISSUED:01/17,2012 OWNER'S PHONE: 4086490;54 PHONE NO: m ^LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT _._ PLUMB License Class Lic.# Ig— L� `�bm n11 ,,A MECH £ RESIDENTIAL t COMMERCIAL ' Contractor ligtl�yr/ft6,iJ MOI-RV—Date IZ I hereby affirm that I arrr licensed under the provisions if Chapter 9 JOB DESCRIPTION:REPLACE FURNACE AND ADD A/C UNIT (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. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$4500 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:35713013.00 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 to building construction,arid hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnity and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18• Issued by: � Date:1-/�/�� Signature Date Z ❑ OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the C'ontractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 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, Signature of Applicant: Date: Business&Professions Code) L as owner of the property,arrr exclusively contracting with licensed contractors to construct the project(See.7044.Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR SETTER I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.9.5 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air 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 I eertifv that in the pertortmance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. not employ arty person in arty manner so as to become subject to the Worker's Compensation Iativs of California. If,after making this certificate of exemption,I Ownor auto ` e t: become subject to(fie Worker's Compensation provisions of the Labor Code,I must Date: ' 1 forthwith comply with such provisions or this permit shall be deemed revoked. ONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address 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 with all non-print source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 22017 mcClellen rd. DATE: 01/17/2012 REVIEWED BY: bobs. APN: BP#: -VALUATION: $4,500 PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition /Repair PRIMARY" SFD or Duplex PENTAMATION FURN/AC USE: PERMIT TYPE: WORK replace furnace and add A/C unit. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES A/C Units (<=10K cfm) 1BREMAIR 1 # $65 Furnace, Forced-Air 1MFR=<100 1 # $130 TOTALS: 1 $195.00 Mech.Plan Check 0.0 hrs $0.00 T T Mech.Permit Fee: IMPERMIT Other Mech.Insp. 0.0 hrs $44.00Ll I ROTE: 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 relinina information available and are ol!lE an estimate. Contact the De t or addn'I in o. FEE ITEMS FEE QTY/FEE MISC ITEMS LLJ A PME Plan Check: $0.00 PME Unit Fee: $195.00 PME Permit Fee: $44.00 Administrative Fee: IADMIN $41.00 Work Without Permit? 0 Yes (j) No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 1BSEL5MICR $0.50 Select an Administrative Item til i r�;= slofl1 : :. IBCBSC $1.00 SUBTOTALS: $325.50 $0.00 TOTAL FEE: $325.50 Revised: 1/01/2012 Building Department City Of Cupertino ELI] 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: Z201 � PERMIT# C%' 2) OWNER'S NAME: PHONE# Lf Mr Cl-06S GENERAL CONTRACT R: ,Q,��r� tTi� BUSINESS LICENSE# ADDRESS: 5cNer s, CITY/ZIPCODE: 4 *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 SUBCONTRACTO VE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Z' Sign re 6ate Please check applicable subcontractors and complete t e 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 Tile Owner/Contractor Signature Efate GENERAL PERMIT APPLICATION MEP Lo COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 (408)777-3228-FAX(408)777-3333- building(a7cupertino.org MISC CUPERTINO ❑PLUMBINGA❑i�CHANICAL ❑ELECTRICAL ❑MISCELLANEOUS T PROJECT ADDRESS - (D ` ,A /1 ! ry��``,�� 1 APN# OWNER NAME �^ �C+ PHO O _ � —�C E-✓MAII. 41 STREET ADDRESS �}— CITY, STATE,ZIP J FAX CONTACT NAME PHONE E-MAII. STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHrrECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAMEt,jj Wjaj �A A�5 I LICENSE NUMBER fsLlq t)711FS� 7CENSSETYPt--,?—C) BUS.LIC# COMPANYNAME c E-MAIL 1A151C)_ Cj y_ ' 0 STREET ADDRESSCITY,STATE PHONE S S h DS � w ArK _ �1 ARCHTTECTIENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK V L TOTAL VALUATION: 1A900 .00 RECEIVED BY: Q� / 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 proed is correct. j have the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buil ' cons; c' .I a oriz epresentatives of Cupertino to enter the abov Iden)fied property for inspection pufposes. Signature of Applicant/Agent: Date: 1 S MENTAL INF TION REQUIRED OFFICE USE ONLY OVER-THE-COUNTER ❑ EXPRESS Y U w ❑ STANDARD r U ❑ LARGE ❑ MAJOR MHPMrscApp_2011.doc revised 06/21/11