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12010108 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22015 It•1C CLELLAN RD CONTRACTOR D PERMIT NO: t2010108 OWNER'S NAME: C1-€AUGUL.E VIJAY AND SANGEETA V ��I /��t� 1(�.�� DATE ISSUED:01/17/2012 OWNER'S PHONE: 4082341465 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class �Z� Lic.# " Z 6 F_- (AA " �" .A MECH RESIDENTIAL COMMERCIAL Contractor l/Q�,Wlf�ry N Lt9bxA L Date � Z... I hereby affirm that I am licensed under the provisions of 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 arid 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:35713012.00 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,and 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,arid 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-paint s'urce regulatiV0ons per t upertino Municipal Code,Section 9.18. Issued b� Date:��,.� Signature ""�� Date 2 ❑ 011'NER-BUILDER CLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1 hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining all 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) I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 2.5534. 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 certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code.Secti 25505,25533,and 25534. not ernploy any person in arty manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I Owner o uth ri g Z11 become subject to the Worker's Compensation provisions of the Labor Code,I must Date: forthwith comply with such provisions or this permit shall be deemed revoked. C _ STRUCTION 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 arid 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 accrete against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply with all non-point 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 7 ITEMS OF 15 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35713012 .00 DATE ISSUED. . . . . . . : 01/17/2012 RECEIPT #. . . . . . . . . : BS000015756 REFERENCE ID # . . . 12010108 SITE ADDRESS . . . . . : 22015 MC CLELLAN RD SUBDIVISION . . . . . . : CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : CHAUGULE VIJAY AND SANGEETA V ADDRESS . . . . . . . . . . : 22015 MC CLELLAN RD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : CARMEN V MUSIAL 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 ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1ADMIN HOURS 1 .00 41.00 0. 00 41 .00 0 .00 1BCBSC VALUATION 4, 500 .00 1.00 0 . 00 1.00 0 . 00 1BREMAIRHA NO.UNITS 1 .00 65 . 00 0 .00 65 .00 0 . 00 1BSEISMICR VALUATION 4, 500 .00 0 . 50 0 .00 0 .50 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 . 50 0 .00 325 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 770 .00 VISA --------------- TOTAL RECEIPT : 770 .00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FI14AL MECHANICAL CITY OF CUPERTINO o FEE ESTIMATOR- BUILDING DIVISION w ADDRESS: 22015 mcClellen rd. DATE: 01/17/2012 REVIEWED BV: bobs. APN: I BP#: VALUATION: 1$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) J 1BREMAIR 1 # $65 Furnace, Forced-Air 1MFR=<100 1 # $130 TOTALS: $195.00 Mech. Plan Check F] his $0.00 T Mech.Permit Fee: IMPERMIT Other Mech.I nsp. Ihrs $44-00 LI NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). TheseLees are based on the prelinsna information available and are only an estimate. Contact the DalLor addn'linLo. F E E ITEMS -�- 1?e.5 i u,� 11-0 i 3 7 1,,11 J MISC ITEMS .... ....................... FEE QTYIFEE PME Plan Check: $0.00 PME Unit Fee: $195.00 PME Permit Fee: $44.00 Administrative Fee: ]ADMIN $41.00 Work Without Permit? 0 Yes 0 No $0.00 Travel DoCUrtientation Fee: I TRA VDOC $44.00 strojw Fe-: IBSEISAIICR Item $0.50 Select an Administrative _j' ynr,.,-Jssjon Fee: IBCBSC $1.00 FSUBTOTALS: $325.501 $0.001 TOTAL FEE: $325.501 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: ZZ ol--5 PERMIT# 0 1 0 Odl- OWNER'S NAME: v & CVyA %A PHONE# 1?— 6 7-q" 3075- GENERAL CONTRACTO ,)&rPt C, , BUSINESS LICENSE# ADDRESS: 5411-f-6 u V%kos•c Aue, lawaL 4' b CITY/ZIPCODE: rw J'4L - q5(1 () *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIO (S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTOR A E OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: ---f Signat re Date Please check applicable subcontractors and complete the�folowing 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 ner/Co&rklor Signature bate GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333- building(cDcupertino.org MISC ❑PLUMBING DfECHANICAL ELECTRICAL ❑MISCELLANEOUS PROTECT ADDRESS 5 /t n ` APN# OWNER NAME ` PHONE 4 oG-Z3�f )cf E-MAIL STREETADDRESS V CITY, STATE,ZIP V FAX CONTACT NAME d L PHO -)-7 S^/,1_ 2J 0.7,5 EET7 E MAII STRADDRESS f 7 CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENI CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME •' LICENSENUMBER O LICENSE TYPE G�.��\ BUS.LIC# AJA 6K) COMPANY NAME E FAX IVA 2 O STREET ADDRESS��S Jn1'�se e J v f, CITY,STATE, ZIP�'Pw�py C1(, 0(� PHO ��^ Q_9R„7� ARCHTTECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# ! J V COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMrLY PROJECT IN WIT DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK � G r TOTAL VALUATION: RECEIVED BY: By my signature below,I certify to each of the following: I am the Xoperty owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have pro ' d is correct. j hav a the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buil ' g construc' I Frze representatives of Cupertino to enter the abfov -identi ed property for inspection putposes. Signature of ApplicandAgent: 1� Date: i 2 S P NTAL >IATION REQUIRED OFFIC1.USE ONLY OVER-THE-COUNTER ❑ EXPRESS Y U S ❑ STANDARD U ❑ LARGE a ❑ MAJOR AEPMise4pp_2011.doc revised 06/21/11