12040110 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22577 SAN JUAN RD CONTRACTOR:SANDIUM PERMIT NO: 12040110
OWNER'SNAME: MICHAELIDHUEY , 4223 VERDIGRIS CIR DATE. ISSUED:04/192012
OWNER'S PHONE: 4089960157 SAN JOSE,CA 95134 PHONE NO:(408)894-9072
�IACENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
IT
License Class Lie.a 2VV I l FURNACE REPLACEMENT AT SAME LOCATION IN
ATTIC,A/C
GoatmeatDate REPLACEMENT REPLACEMENT AND RELOCATE, DUCT REPLACEMENT
1 hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 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:$22000
I 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 APN Number:34217084.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMITE SIF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN YS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned properly for inspection purposes. (We)agree to save 180 DAYS M LAST CALLED INSPECTION.
indemnity and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of of Nis permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-pointsource regulations per the Cupertino Municipal Code,Section
Sign. 'I 1/�- �7- 2
RE-ROOFS:
!! ��
Signature Date All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without fust obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I em exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505.25533,and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Section 505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this .1
Owner or authorized agent Dale:
permit is issued.
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
Compensation laws of Califomia. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGF.NCV
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this peril.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO s�
FEE ESTIMATOR- BUILDING DIVISION �. 'D40M)
ADDRESS: 22577 San Jaun Rd. DATE: 04119/2012 REVIEWED BY: gs
APN: BP#: 'VALUATION: $22,000
PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: PERMIT TYPE:
WORK Furnace replacement with duct work. Replace A/C at new location.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $130
A/C Units (<=10K cfm) 113REMAIR 1 # $65
Heating System 1 # $65
TOTALS: $260.00
Mech. Plan Check 0,0 hrs $0.00 Plumb. Pic..CherA !ilce. P/... Chrck
Mech.Permit Fee: IMPERMIT 1'1u+nh. Permit Fre: lilec. Penni[Fec:
Other Meeh. Insp. 1 0.0 hrs $44.00 Other Plutnh Imp. Ej Other like. lap. Li I
Rcch. hi'p. Fr c: Plun+b. lnep. A-.': Ele.c. Dnp. Fcc.'
NOTE: This estimate does not includejees due to other Departments(Le. Planning,Public Works, Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on die prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resohaion 11-05310. 711111) FEE QTY/FEE MISC ITEMS
Plan Chuck Fee
.Supp!. PC Fee
PME Plan Check: $0.00
Permit Fee:
Supp/. lisp Feu
PME Unit Fee: $260.00
PME Permit Fee: $44.00
Cunslrm lion Tay.
Administrative Fee: (ADMIN $41.00
Work Without Permit? 0 Yes Q No $0.00
Advanced Planning hies':
Travel Documentation Fee: ITRAVDOC $44.00
Strong Motion Fee: IBSEISMICR $2.20 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 1 $392.20 $0.00 TOTAL FEE: 1 $392.20
Revised: 04/01/2012
CITY OF CUPERTINO
8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: counter
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 34217084 . 00
DATE ISSUED. . . . . . . : 04/19/2012
RECEIPT # . . . . . . . . . : BS000016582
REFERENCE ID # . . . : 12040110
SITE ADDRESS . . . . . : 22577 SAN JUAN RD
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER MICHAEL J DHUEY
ADDRESS 22577 SAN JUAN RD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-3932
RECEIVED FROM . . . . : MICHAEL LEE
CONTRACTOR MICHAEL LEE LIC # 28867
COMPANY SANDIUM
ADDRESS 4223 VERDIGRIS CIR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95134
TELEPHONE . . . . . . . . : (408) 894-9072
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- --------- - ---------- ----------
1ADMIN HOURS 1 . 00 41. 00 0 .00 41 . 00 0 . 00
1BCBSC VALUATION 22, 000 .00 1 . 00 0 . 00 1 . 00 0 . 00
1BREMAIRHA NO.UNITS 1 .00 65 . 00 0 . 00 65 . 00 0 . 00
1BSEISMICR VALUATION 22, 000 . 00 2 .20 0 .00 2 .20 0 . 00
1MFR=<100 UNITS 1.00 130 .00 0 . 00 130 . 00 0 . 00
1MPERMITFE FLAT RATE 1 .00 44 . 00 0 .00 44 .00 0. 00
1MRRAA UNITS 1.00 65. 00 0 .00 65 . 00 0 . 00
1TRAVDOC FLAT RATE 1 .00 44 .00 0 . 00 44 .00 0. 00
---------- ---- ------ ---`------ ----------
I
TOTAL PERMIT 392 . 20 0 .00 392 .20 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 392 .20 visa
---------------
TOTAL RECEIPT 392 .20
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
------ ---- ------------------------ -------- -------------------------- - -
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
GENERAL PERMIT APPLICATION M E p
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 I A
CUPERTINO (408)T77-3228•FAX(408)777-3333• buildina(a cuoertino.ora (v_
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PROIFYT ADDRESS 'L2$ / 7 1�� . Na 3z/{/a -1,7 -Del/
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OWNERNAME -.fI ' 11 PHONE j 9q6 D(5 E-XAM
STREETADDRESS sI— QTY,STATE ZIP I FAX
CONTACT NAME •7^ v PHONE E-MAIL
STREETADORM CITY,STATE,ffi FAX
13 OWNER ❑ OWNER-BUDDER ❑ OWNER A= NTMCTOR ❑WNTMCTOR AGENT ❑ Aac urwr ❑ENGDI}R ❑ DEVEIDPEa ❑TENANT
CONTRACTOR NAME LICENSE NUMBER 1 I cDw TYfE' + ROS.LIC p r
COMPANY NAME I_A1 E-MAIL yy5 ` Iw_ Qw rc' !�w'V. FAX
MEETAIIDREL4 �rs�f 3 QTY.STATE ZP C A J lsa PHONE *9 89440 /
ARCHMEMENGINEER NAME(E LICENSE NUMBER a HUs.LIC#
COMPANY NAME E-MAR. FAX
TrJ EET ADDRFM CITY,STATE IIP PHONE
USE OF w DUPLEX ❑ MULTFFANGLY PROIECTIN WIDL ND YES PROIECC W ❑YES D THE BLDG M YES
BUDDING: ❑commmCW. URBAN INTERFACE AREA ❑ NO FTDOD ZDNE [I NO IIf3ItRHOMkI NO
DESCRIPTION OF WORK 1 ,�
u,( Q,t Sar• K WAP %Z,
t o �
TOTAL VALUATION: RECEIVED BY:
Hy my signature below,I certify to each of the followmg. I am the properly Owner m authorized agent to aR on the propekowtIces behalf I have read this
application and the i 6 adca I have provided is correct J have read the Description.of Work and verify it is accurate. I ague to comply with all applicable local
ordmaaees and Stan laws relating to>Mpg ooasstrocti I authorize represe vad.ves of Cupertino to cuter the above-identified property far inspection poo'poses.
Sigcettue ofAppEmcu
nr/Agc //l/��f Date:
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
u ❑ OVFII-THE-COUNTER
❑ VIPR.FSS
Id
— ❑ STANDARD
❑ URGE
❑ MAJOR
MEPMtrcdpp_2011.doe revised 06121111