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11090210 ;CI -01+CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21760 LOMITA AVE CONTRACTOR:AIR QUALITY HEATING PE RMIT NO: 11090210 &AIR OWNER'S NAME: BIRAN DORIT 720 NORTHRUP ST DATE. ISSUED:09/30/2011 OWNER'S PHONE: 4086790682 SAN JOSE,CA 95126 PHONE NO:(408)293-7138 LICENSED CONTRACTOR'S!DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL. License Class�_ Lic.N 6 INSTALL NEW A/C UNIT Contractor—,94 _WA_t4�Date 1 hereby aRrm that 1 am licensed under the provisions of Che ter 9 (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. Sq.FI Floor Area: Valuation:$3500 1 have and will maintain Worker's Compensation Insurance,m provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued_ ra,r- _ APN Number:35718040.00 Occupancy Type: APPLICANT CERTIFICATION ��/�/ I certify that 1 have read this application and slate that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED cored. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYSO LAST CALLED INSPE TI indemnify and keep hamhless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the /XI C // granting of this permit. Additionally,the applicant understands and will comply Issued by: / Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RF.-ROOFS: Signature Date All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for r inspection. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: 1 hereby affirm that I em exempt from the Contractor's License Lew for one of the following two reasons: I 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 sole(Sec.7044, Business&Professions Code) I,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 penally 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(x)should 1 store or handle hazardous 1 have and will maintain a Ccnificate of Consent to self-insure for Worker's material. Additionally,should 1 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 1 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,Sections 5505,25533,and 25534. Section 3700 of the Labor Cade,for the performance of the work for which this Owner or authorized agent: WAL��= Date: i 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 California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,1 must I hereby ammh 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 1 have read this application and stale 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, 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 permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9,18. Signature Dale CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION ADDRESS: 21760 lomita ave. DATE: 09130/2011 REVIEWED BY: bobs. APN: BP#: 'VALUATION: $3,500 „PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD Or Duplex PENTAMATION FURN/AC USE: PERMIT TYPE: WORK install new a/c unit SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES A/C Units (<=10K cfm) 1BREMAIR 1 # $65 TOTALS: $65.00 Mech. Plan Check 0.0 hrs $0.00 Ph"'11), Plan C4cnk Mech. Permit Fee: IMPERM/T Plund•. Pelvih Fec Other Mech. Insp. 0.0 hrs $44.00 r")rl,rr 1'lunrh In.:p. Li I 0bhc• i1sr.. lu,pEl arch, Inv, Fee.: fluor".. br.!p. 1-b,c iilvr. Imp re": NOTE: This estimate does not Includejees due to other Depts(i.e. Public Works,Sanitary Sewer District,School District,etc.). These fiTs are based on lite preliminarp in ormallon available and are only an estimate. Contact lite Dept for addn7 info. FEE ITEMS (Fee Resolution 11-0531iIT %'1/11) FEE QTY/FEE MISC ITEMS 1'Iwr Check 1-ce: .Supp/. PC Pec PME Plan Check: $0.00 P(onil Fce SupP11r1sp bee PME Unit Fee: $65.00 PME Permit Fee: $44.00 Co ytrucri:m '1'nr Administrative Fee: !ADMIN $41.00 Work Without Permit? Q Yes 0 No $0.00 Advara erll'lannirr� Fees: Travel Documentation Fee: ITRAVDOC $44.00 Strone Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bide Sids Commission Fee: IBCBSC $1.00 SUBTOTALS: $195.50 $0.00 TOTAL FEE: $195.50 Revised: 09/02/2011 GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO. CA 95014-3255 M I /� CUPERTINO (408)777-3228• FAX(408)777-3333• buildino(cDcuoertinc.oro ,v" w ,�� i Ip9j 02-10 e L1 CAL ELEcrn CAL ❑MISCELLANEOUS PROJECT ADDRESS 7-' --T ^O /-OM r - /1 , APN4 0 o OWNERNAME Bir4P1 PHONE _ EMAIL 14 z� 6J 6-L 9 STREET ADDRESS L4-4VZ� CITY. STATE ZIP FAX CONTACT NAME `/Lt PHONE D� C E-MAIL STREETADDRESS Jt+l .I / ry] CRY,STATE, D` 0 FAX ❑ OWNER ❑ OWNER-BUDDER ❑ OWNER AGENT 13 CONTRACTOR 11 CONTRACTOR ADEM ❑ ARCHITECT ❑EHGOJEER ❑ DEVEIZPER ❑ TENANT CONTRACTOR NAME ,t�,r LICENSE ER / LICENSE TYPE BUS,IJCN COMPANY NAME /�4 E-MATE (O FAX /� STAFFT ADDRESS -�- CRY,STATE,ZAP F/Z411 PHONE '�/J� /y/4 ARCHRECTIENOINEER NAME LICENSE NUMBER l BUS.LIC N 7 COMEA.NY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SMarDUPr CY ❑ MULTEFAT.tLLY PROJECTIN WtLDLWD ❑ YES PROJECTIN ❑ YFS IS THE BLDG AN ❑ YES BUILDING: ❑CDMMERCTAL I URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHIER HOIE. 0 DESCRIPTION OF WORK 1,2 C 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 rrad this application and the information I have pmvide 's correct,f 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 buil -W etion`I authorize representatives of Cupertino to enter the above-iden fled Pro ertl'for inspection pu(poses. Signature of Applirant1Agent: Dam: SUPPILPENTAL INFORMATION REQUIRED OFFICE USE ONLY u OLS VFIt- E,COUNTER ❑ EXPREss U u ❑ STANDARD U J ❑ LARCE ❑ MAJOR MEPAIIscApp_2011.doc revised 06121111 CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng,: Sub: Blk: Lot: APN . . . . . . . . : 35718040.00 DATE ISSUED. . . . . . . : 09/30/2011 RECEIPT #. . . . . . . . . : BS000014915 REFERENCE-:ID # . . . : 11090210 SITE ADDRESS . . . . . : 21760 LOMITA AVE SUBDIVISION . . . . . . CITY . ... ... . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : BIRAN DORIT ADDRESS 21760 LOMITA AVE CITY/STATE/ZIP . . . : CUPERTTNO, CA 95014 RECEIVED FROM . . . . : MATTHEW FARBER CONTRACTOR . . MATTHEW FARBER LIC # 22791 COMPANY AIR QUALITY HEATING & AIR ADDRESS 720 NORTHRUP ST CITY/STATE/ZIP '. . . : SAN JOSE, CA 95126 TELEPHONE. . . . .. . . . : (408) 293-7138 FEE ID UNIT IQUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- -------------- ---------- --- ------ - ---------- ---------- ---------- -ADMIN HOURS 1 .00 41. 00 0 . 00 41 . 00 0. 00 1BCBSC VALUATION 3, 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 ' 3, 500 .00 0 . 50 0 . 00 0 .50 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 195. 50 0 .00 195.50 0 . 00 METHOD OF PAYMENT AMOUNT- REFERENCE NUMBER -------- --------- --------------- -------------------- CREDIT CARD 195 . 50 me --------- ------ TOTAL RECEIPT 195 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL