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12050055CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21862 LINDY LN OWNER'SNAME: CHEN JENNIFER AND SMITH MARK OWNER'S PHONE: 4085699643 ❑ LICENSED CONTRACTOR'S DECLARATION License Class , 11>,l<) Lic, 4 J'L-(p0.0-'>- Contractor ";Eb,AsRESCF. Date11}- 1 hereby affirm that I um 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. 1 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. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is cored. 1 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 indemnifyand keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this til. Additio ally, the applicant understands and will comply with all non- pint s per the Cuperino Municipal Code, Section 9.18, Signalur Date—S% ❑ OWNER-BIIILDF.R DECLARATION I hereby afrrm that 1 am exempt from the Contractor's License Law for one of the following two reasons: I. as owner ofthe properly, 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) I, as owner of the property, am 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 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 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I cenify 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 become subject to the Worker's Compensation provisions of the Labor Code, I most forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that I have read this application and slate that the above information is correct. 1 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, costs, and expenses which may accrue against said City in consequence of the 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. CONTRACTOR: ALLIED AIRE SERVICE INC PERMIT NO: 12050055 470S HILLVIEW DR DATE ISSUED: 05/042012 MILPITAS, CA 95035 1 PHONE. NO: (408)934-8844 BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r MECH r RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION: REMOVE AND REPLACE FURNACE, A/C, AND DUCT WORK IN SAME LOCATIONS Sq. Ft Floor Area: I Valuation: $12000 APN Number: 35624018.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by:.�Eii/� Alq �w Date: ,s•'� •/� RF: ROOFS: All roofs shall be inspected prior to any roofing material beng installed- If a roof is installed without first obtaining an inspection, 1 agree to remove all new materials for inspection. Signature of Applicant: Date ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(x) should 1 store or handle hazardous material. Additionally, should 1 use equipment or devices which emit hazardous air contaminants as defined y the Bay Area Air Quality Management District I will maintt' compliance the Cupertino Municipal Code, Chapter 9.12 and the Health $ Sa clionQ5505, 25533, and 25534. O o or t or ge .L Dale: S CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Dale I Licensed 7 ITEMS OF 7 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 35624018.00 DATE ISSUED.......: 05/04/2012 RECEIPT #.........: BS000016710. REFERENCE ID # ...: 12050055 SITE ADDRESS .....: 21862LINDY LN SUBDIVISION ....... CITY CUPERTINO IMPACT AREA ....... OPERATOR: patg COPY # : 1 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT AMOUNT ---------326.20 --------------- 326.20 VOICE ID DESCRIPTION ---------------------------- 505 FINAL ELECTRICAL 508 FINAL MECHANICAL REFERENCE NUMBER -------------------- #22925 VOICE ID DESCRIPTION ---- -------------- 507 FINAL PLUMBING OWNER ............: CHEN JENNIFER AND SMITH MARK ADDRESS ..........: 21862 LINDY LN CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: ALLIED AIRE SVC INC CONTRACTOR .......: STEINER, ARNOLD R LIC # 19207 COMPANY ..........: ALLIED AIRE SERVICE INC ADDRESS ..........: 470 S HILLVIEW DR CITY/STATE/ZIP ...: MILPITAS, CA 95035 TELEPHONE ........: (408)934-8844 FEE ID - UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW SAL -ADMIN ----------- ---------- HOURS ---------- - 1.00 41.00 0.00 ---- 41.00 ---------- 0.00 1BCBSC VALUATION 12,000.00 1.00 0.00 1.00 0.00 1BREMAIRHA NO.UNITS 1.00 65.00 0.00 65.00 0.00 1BSEISMICR VALUATION 12,000.00 1.20 0.00 1.20 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 1TRAVDOC FLAT RATE 1.00 44.00 0.00 44.00 0.00 TOTAL PERMIT 326.20 0.00 326.20 0.00 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT AMOUNT ---------326.20 --------------- 326.20 VOICE ID DESCRIPTION ---------------------------- 505 FINAL ELECTRICAL 508 FINAL MECHANICAL REFERENCE NUMBER -------------------- #22925 VOICE ID DESCRIPTION ---- -------------- 507 FINAL PLUMBING GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 950143255 M' /� CUPERTINO �� (v' ❑PLUMBING MECHANICAL ❑ELECCRICAL I IMTSCETIAN-FnT7C (408) 777-3228 •FAX (408)777-3333 • buildinO(dcu[)ertinD.o PROJFIT ADDRESS Chi OWNER NAME AA ��I� SyV:IT `'$lv�a� L- 3 PNON`E402 60-%43 EMADa,� STAEETADDRM !!y /-� FAX CONTACT NAME PHONE - E -MAD. STREETADDRESS CITY, STATE. ZD' FAX ❑ OWNFR ❑ OWNFJt-9ULLOFCI OWWERAGINi DIOOImt ❑ DEveLOPPA ❑ TewTr mMRACIOR ❑aWTTRArCIORAGFNT ❑ AROQfTF1ypT '�-jam❑ CONIRACIORN g -C JI.�%li'I L'�� ucENYmi 1 ]❑ G�p E JQ B'UUSS.LLIC ## COMPANY CDs'YI6 T(V 9FLLPFJ. STRBFT /7 S . ,.•s—w�- 1J TY" ATE S G/� 91-03r / , �T 54"'404, y Tu 9-W PTW 9.Tf'88` 4f ARCHTTELT/ENGDTEEA NAME - LICENSE NUMBER BUS uc CONOANY NAME ' E-MAIL FAX STREFt' ADDRESS CITY. STATE. ZIP PHONE USE OF SFO mOUPLEX ❑ MOLTFFAMRY BOaDTNO: ❑ cGK%ERrTA 1PRO=1N WRDI-WD ❑ YE4 ' URBAN INTERFACE AREA NO PROTECT EN ❑ YEs FLOOD ZONE NO MTHEBLDGAN ❑ YES EICTD.Or HOMM NO DESCRIPTION OF WORK TOTAL VALUATION: /a ODO RECEIVE[) BY: By my sigaatme below, I certify toeach full ' g'. I application and the i�'rnmatio¢ I hav otdi¢mca and stain laws relating Signa¢ne ofAppli®NAgea¢ the property owner ar antirorin:d agent to act on the property awnees behalf. I have read this d the Dela on of Work and verify it is aacmate. I agree to comply with all applicable local authar=' wdves of Cupertino to enter the above -i entified perty for iaspectio¢ puFpases. Dam: SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY u Id OYER -THE -COUNTER 6 Y ❑ EXPRESS u u u ❑ STANDARD ❑ LARGE ❑ MAJOR MPPMarApp_1011.doc revised 06121111