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12050175CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20847 IiANPORD DR CO\"I'RAC'1'Olt! AAA Pel li\ACIi R AIR PFR>II"f X'O: 12050175 CONIJI'1-I0NIN'G OWNER'S NAME: NANCY & I IIRAM SIBLEY 1712 S'l'ONF AVL DATE ISSUED: 05/23/2012 OWNER'S PHONE: 4085908741 S,\N.IOSF,,C:\ 95125 ruONK NO: (4(181293-4717 ❑ LICENSED CONTRACTOR'S DF,CLARA-1ION' r r r / `C. � - BUILDING PERi111'1' INFO: BLDG ELECTPLUd1B -260D License Chess C.-zC I,ic.is r— r r r /� /� n Contractor AN I C I V ol&( - Date. _Z //_7 '- 41k:CII RESIDENTIAL I hereby affirm that I am licensed under the provisions of Chu pier 9 JOB 1) ESC RIP II ON: INS'(-AIJ. AIC '10 LXIS'I'INC FURNACE (commencing with Section 7000) of Division 3 of the Business & Professions Code :old that ms' license is in full force and effect. I hereby affirm under pemdqof 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, ti Ft Floor Area: q Valuation: 57100 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. ,\PN Number: 32630074.00 Occupancy "I %pe: AI'PI,ICAN'I' CF.RTI F IC,\TION I certify that I have read this application and state that lhe'above information is correct. l agree a, comply with Ell cityand county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NO"1-STARTED to building construction, and hereby authorize representatives of this city to enter upon die above mentioned property for inspection purposes. (We) agree to save WITHIN 180 DAYS OF PERMITISSUANCE OR indemnify mid keep harmless file City ol'Cupertino against liabilities,judgments, 180 DAYS FROM LASTCALLED INSPECTION.costs, and expenses which may accrue against said City in consequence of the eraming of this permit. Additionally, the applicant understands and will comply with all nun-point source regulations per the Cupertino Municipal Code. Section �7/ �, J/ 7 Issued by: /E4111 T 4n:TG � Dater-�: l 9.18. _ Signature Gu. — Dote -,73-/—z— RF:-ROOFS: ❑ OWNER-BUILDER DECLARATION All roofs shall he inspected prior to any roof ng material being installed II'a roofis Installed N'Idmin first obtaining all inspection, I agree to rernme all Ileo materials her I hereby affirm that 1 am exempt from the Contractor's License Law for one of inspection. the followinngg two reasons: I. as owner of the property. or my employees with wages as their sole compensation. Signature of Applicant: Date: will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) L as owner of the property, and exclusively contracting with licensed contractors to AL1, ROOF COVERINGS "10 13E CLASS "A" OR Ilk', ITER construct the project (Sec.7044, Business & Professions Code). 1 hereby affirm under penalty of perjury one of the following three 11,\Z:\RDOUS >L\1'ERIALS DISCLOSURE declarations: 1 have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certlficme ol'Conscnl to self-msurc for Worke'r's California Health & Safcly Code, Sections 25505, 25533, and 25534. I will maintain Compensation, as provided for by Section 3700 ol'the Labor Code, for the compliance with the Cupertino Municipal Code. Chapter 9.12 and the Health & perform: nce of(he work lin which this permit is issued Safey Cade, Seclion'_5532(1) should I store or handle hazardous material. I hate and will maintain Worker's Compensation Insurance, as provided for by Additionally, should I use equipment or devices which emit hazardous air Section 3700 ol'the Labor Code, for the performance of the work for which this contaminants as defined by the Bac Area Air Quality Ahumgenm•nt District I is ill maintain compliance ss'ith tilt• Cruperlino Municipal Code, Chapter 9.R and the permit is issued -- 255 Ilrltllh & Safrh' Cale, Sec limen _5.115. _5,3J.:_�� uul J4. I cerlil)' that in the performance ml the work for which This permit is issued (shall not employ any person in any manner so as to become subject to the Worker's Ox get or authu Compensation laws of Cafit'urnia. 11'. after making this certificate of cxemplion. I Date: 7 become subject to dile Worker's Compensation provisions of the Labor Code, I must Ibrthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construct mi Iending agency fior the• per ((rill all cc of mork's APPLICANT CERTIFICATION far which this permit is issued (See. 3097. Civ C.) I certil)'that I have read this application ;end state that the above information is Lender's Name correct. I agree to comply with ed1 city and county ordinances and stale laws relating to building construction, and hereby oulhorize representatives of this city to enter Lender's Address upon the above mentioned property for inspection purposes. (We) agree to save indemnily and keep harmless the Ciy of Cupcnino against liabilities. judgments. and expenses which may accrue against said City' in consequence of the ARCII I'I'F:CI"S DECLARATIONcosts, grinding of this permit. Additionally, the applicant understands and will comply I understand me plans shall he uscJ as public records, with all non-point source regulations per the Cupertino Municipal Code, Section 9 18. Licensed Prolessionul Signature Doc 8 ITEMS OF 8 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32630074.00 DATE ISSUED.......: 05/23/2012 RECEIPT #.........: BS000016888 REFERENCE ID # ...: 12050175 SITE ADDRESS .....: 20847 HANFORD DR SUBDIVISION ....... CITY CUPERTINO IMPACT AREA ......: OPERATOR: suew COPY # : 1 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT AMOUNT --------------- 283.71 --------------- 283.71 VOICE ID DESCRIPTION -------- ---------------------------- 505 FINAL ELECTRICAL 508 FINAL MECHANICAL REFERENCE NUMBER -------------------- 40259 VOICE ID DESCRIPTION -------- ---------------------------- 507 FINAL PLUMBING OWNER ............: NANCY & HIRAM SIBLEY ADDRESS ..........: 871 SWAN DR CITY/STATE/ZIP ...: MANTECA, CA 95337 RECEIVED FROM ....: AAA FURNACE CONTRACTOR .......: RANDO,.JIM LIC # 8050 COMPANY ..........: AAA FURNACE & AIR CONDITIONING ADDRESS ...........: 1712 STONE AVE . CITY/STATE/ZIP ...: SAN JOSE, CA 95125 TELEPHONE ........: (408)293-4717 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC ---------- NEW BAL ---------- ---------- -ADMIN ------------- ---------- HOURS 1.00 ---------- ---------- 41.00 0.00 41.00 0.00 1BCBSC VALUATION 7,100.00 1.00 0.00 1.00 0.00 1BREMAIRHA NO.UNITS 1.00 65.00 0.00 65.00 0.00 1BREMRECEP NO. OUTLETS 1.00 44.00 0.00 44.00 0.00 1BSEISMICR VALUATION 7,100.00 0.71 0.00 0.71 0.00 1EPERMITFE FLAT RATE 1.00 44.00 0.00 44.00 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 -------------------- 283.71 0.00 283.71 0.00 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT AMOUNT --------------- 283.71 --------------- 283.71 VOICE ID DESCRIPTION -------- ---------------------------- 505 FINAL ELECTRICAL 508 FINAL MECHANICAL REFERENCE NUMBER -------------------- 40259 VOICE ID DESCRIPTION -------- ---------------------------- 507 FINAL PLUMBING �� CITY OF CUPERTINO ISD' FEE ESTIMATOR — BUILDING DIVISION L-MEDR77E7SS: 20847 Hanford Dr. DATE: 05/23/2012 REVIEWED BY: RDW APN: BP#: lc20.50 'VALUATION: 1$7,100 ''PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Duplex USE: I'ba„1,. I`, PENTAMATION FURN/AC PERMIT TYPE: WORK Add A/C to existing furnace. SCOPE ()//1,,1,11wil, bn1" NOTE: Thl.s estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact lire Dept for addn7 into. FEE ITEMS (I'ee Resolution 11-053 Eff 7/1/11) FEE QTY/FEE MISC ITEMS Mech. Plan Check 0.0 hrs $0.00 nl,,,,d. 14.,,, r'Lrr!r Elec. Plan Check 0.0 1 hrs $0.00 Mech. Permit Fee: IMPERMIT I'ba„1,. I`, Elec. Permit Fee: IEPERMIT Other Mech. Insp. 0.0 hrs $44.00 ()//1,,1,11wil, bn1" Other Elec. Insp. Ehrs $44.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. Q OT F0,0Thrs NOTE: Thl.s estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact lire Dept for addn7 into. FEE ITEMS (I'ee Resolution 11-053 Eff 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = # $65.00 Mechanical 1BREMA/R I A/C Units (<=10K cfm) Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 PME Plan Check: $0.00 1 $44.00 Electrical 1BREMRECEP Recep/Switch/Outlets Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. Q OT F0,0Thrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $88.00 c ",,,;•.�,.,..,_., 1.,. Administrative Fee: IADMIN $41.00 O E) Work Without Permit? O Yes Q) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure (F) O A Travel Documentation Fee: 1TRAVDOC $44.00 Strong, Motion Fee: 1BSEISMICR $0.71 Select an Administrative Item 131de Sids Commission Fee: IBCBSC $1.00 SUBTOTALS: 1 $174.71 $109.001 TOTAL FEE: $283.71 Revised: 05/01/2012 GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO. CA 95014-3255 I CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • buildinD(DDcupertino.Dra LUNIBING 61ECHANICAL ELEC TICAL ❑SIISCELLANEOUS EP PROJECT ADDRESS / ( }d 1 li Gl/1jl ��tl. &Ir f•O (i`�'Si'IOLf— 1, `Jv (IL�2. APNi T . U Z (I /i5�LJ OWNER NAMEAN n r / (y` -I I{IJ pqo i EMAJL STREET ADDRESS STATE. FAX�q� �Q C CONTACT NAMEPNo /j ��,•'Zpr �I YY Tl.�l VT/'"f IV •-O 1 it E- V 1 t 11K -�P Ys�i�. �M STREET ADDRESS \I I Mh •� Crry.STATE, Z9('Nn C J1V1"T� i�W UlA ov l/yl Fa�4IT( ❑ OWNER ❑OWNER-BtJILDE0. ❑ OWNERAGENT XCONTRALTOR VCON CTORAG1DTT ❑ ARCRRECT ❑ ENGt.NEER Cl DEVELOPER ❑ iFNAM CONTRACrORNA.NE W .�1�/tA/IM. 1V��YY�YY��I/��VJ/� LICENSE N"Ell-I I rr/�//.�tW—EA V BUS. UCd 1 0 50 11MAIL CONO'ANY NAMEEA�obt O(e, -MYr F Fj� lit �r�t ��1� Jr TAV1c,A r - CiTY. SFATE. STREET ADORFS50 111V M Raw �• -Irl i t-hel 'ry' L13 1 -34 ARCHITECTENGINEERNAME LICENSE NUINBER BUS. LICA COMPANYN&. M E-MAIL FAX STAIFr ADDRESS CrrY, STATE. ZIP PHONE EE USE OF $FDOr Duplex ❑ Multi -Family PROJECTINWB.DLAND PROJECTIN TR SUCTURE: ❑ Comerc mial q/`. " URBAN INI'FRPAREA ACE AR- ❑ Yes /Ll �o I FLOOD ZONE ❑ Yes ❑ NO DESCROM, ON OF WORK Add 7a C5- F� TOTAL VALUATION: -� t/ r Y '-'iv"•^?• -�- _ �, q, �V CIIYEDB.ti �:1 �•�V4 'ti a �-� SC. By my signature below. I certify to each of the f011awing: 'I am the property Owner or authorized agent to act On the property owner's behalf. I have tad this application and the information I have provided is carrecL I have read the Description Of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. 1 authorize representatives of Cupertino to enter the above -1 property for impection purposes. Signature afApplicanNAgenC - Dat: ;4;d ci MITce.renm.r nrcn.r... �•..... ...........__ MEPM1rc4pp_2011.doc revised 03/16/11