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12020027 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 8058 PARK VILLA CIR CONTRACTOR:GOSAL HEATING&AIR PERMIT NO: 12020027 CONDITIONING OWNER'S NAME: YEDLA SANJEEVA R AND VELPULA SUNAND 34492 TORREY PINE LN DATE ISSUED:02/07/2012 OWNER'S PHONE: 4085938555 UNION CITY,CA 94587 PHONE NO:(510)441-2318 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT ' PLUMB ' License Class Lic. 6, &b COMMERCIAL Contractor G 0 ih J� Date —7 MECH RESIDENTIAL JOB DESCRIPTION:FURNACE CHANGE OUT AND A/C REPLACEMENT I hereby affirm that.I am licensed tinder the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business&Professions FURNACE Code and that my license is in full force and effect. 58HD-XO60112 95%EFF SINGLE STAGE A/('-'24ABB336(3 TONS)SEE 14 1 hereby affirm tinder 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 tile performance of the work for which this permit is issued. [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 permit is issued. Sq.Ft Floor Area: Valuation:$6200 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:35610033.00 Occupancy Type: 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 upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of C.upertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-point source regulations ois per the Cupertino Municipal Code,Section 180 DA S FROM ► CALLED INSPECTION. 9.18. Signature Date Issued by: Z— Date: ❑ OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1,as owner of the property,or nly employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection. Business&Professions Code) Signature of Applicant: Date: 1,as owner of the property,arn exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE 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 read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of(fie Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will not employ any person in any manner so as to becorne subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534. become subject to the Worker's Compensation provisions of the Labor Code,I mustO r r authorized agent- forthwith comply with such provisions or this permit shall be deemed revoked. Date: ,L— APPLICANTCERTIFICATION CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of w)rk's to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(See.3097,Civ C.) upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name indemnity and keep harmless the City of Cupertino against liabilities,judgment-,, costs,and expenses which may accrue against said City in consequence of the Lender's Address granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECTS DECLARATION 9.18. 1 understand rtty plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 7 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg COPY # Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35610033 . 00 DATE ISSUED. . . . . . . : 02/07/2012 RECEIPT #. . . . . . . . . : BS000015946 REFERENCE ID # . . . : 12020027 SITE ADDRESS . . . . . : 8058 PARK VILLA CIR SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : YEDLA SANJEEVA R AND VELPULA S ADDRESS . . . . . . . . . . : 8058 PARK VILLA CIR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : GOSAL HEATING&AIR C CONTRACTOR . . . . . . . : KESAR SINGH LIC # 22229 COMPANY . . . . . . . . . . : GOSAL HEATING & AIR CONDITIONI ADDRESS . . . . . . . . . . : 34492 TORREY PINE LN CITY/STATE/ZIP . . . : UNION CITY, CA 94587 TELEPHONE . . . . . . . . : (510) 441-2318 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 6,200 .00 1. 00 0 .00 1.00 0 . 00 1BREMAIRHA NO.UNITS 1 .00 65 . 00 0. 00 65 .00 0 .00 lBSEI'S-MICR VALUATION 6,200 .00 0.62 0 .00 0 .62 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 .62 0 .00 325 .62 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 444 .62 #2709 --------------- TOTAL RECEIPT 444 .62 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- SOS FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 8058 park villa circle DATE: 02/07/2012 REVIEWED BY: larry s APN: BP#: VALUATION: EZ11:000 PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION FURN/AC USE: PERMIT TYPE: A WORK furnace change out.and a/c replacement furnace 58hdx060112 95% eff. single stage a/c 24abb336 (3 SCOPE tons)seer 14 APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Furnace, Forced-Air _j 1MFR=<100 1 # $130 A/C Units (<=10K cfm) 1BREMAIR 1 # $65 TOTALS: $195.00 N4ech.Plan Check Fo-o1hrs $0.00 Ftech.Permit Fee: IMPERMIT Other N4ech.Insp. 0.0 hrs] $44.00 A10TE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). Thesef�Zes are based on the L!relining inforniation available and are o or addn'lin o. an estittiate. Contact the Df E1 FEE QTY/FEE MISC ITEMS FEE ITEMS e"Y"'Ce )?esU/1.1-(?'y 11-04, k'frr 7-1,, 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 (2) No $0.00 Travel Documentation Fee: I TRA VDOC $44.00 1BSEL5A41CR 0 Select an Administrative Item g_ (ol-lirrilssion Fe,,:e- IBCBSC , S 1 110 SUBTOTALS: $329.50 $0.00 TOTAL FEE: 950 Revised: 1/19/2012 4 2 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(5cupertino.oL ❑PLUNOING MECHANICAL ❑ELECTRICAL [:]MISCELLANEOUS f / PROJECT ADDRESS ' "'PN -7;OWNER NAME ' _a PHONE -MATT. STREET ADDRESS STATE,ZIP , � FAX CONTACT NAME H S/C -�7/Z, E-MA1L13 STREET ADDRESS �, , CITY,STATE, ZIP FAX .-, mow_ ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE C'7 , BUS.LIC# N � C; Gy L-1J COMPANY NAME STREET ADDRESS /K. CITY'ST ZII' - y 9 f ^�.--�,, /moi 1 PHO L1 _.S �J 7� ARCHITECTIENG LICENSE NUMBER BUS. COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF IMSFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WIIALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BURRING: COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK �- MA G Z7,2 le A/J4 _ z,-? 34 TOTAL VALUATION: RECEIVED BY: 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.,have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating i cling constructions I tho' e representativ of Cupertino to enter the above-i tified perty for inspection poses. r � ' Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY OVER-THE-COUNTER a ❑ EXPRESS x U w ❑ STANDARD U ❑ LARGE ❑ A4AJOR MEPMzscApp_2011.doc revised 06/21111