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12060111 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22192131TTER OAK ST CONTRACTOR:CHAND ADITYA AND PERMIT NO: 12060111 RUCHI OWNER'S NAME: CIIAND ADITYA AND RUCIII 22192 BITTER OAK ST DATE ISSUED:06/19/2012 OWNER'S PHONE: 4088910458 CUPERTINO.C\ 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r License Class Lic.p MECH RESIDENTIAL COMMERCIAL Contractor Dale 1 hereby affirm that 1 am licensed under the provisions of Chapter 9 306 DESCRIPTION: REMOVE AND REPLACE A ROOF TOP A/C SYS]17M (commencing with Section 7000)of Division 3 of the Business&Professions (TRANI: Code and that tar license is in full force and effect. XB 13 2-1'ON) 1 hereby affirm under penally 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 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 Sq.Ft Floor,%rea: Valuation:$2805 permit is issued. APPLICANT'CF,RTIFICAT'ION AIN Number:32651046.00 Occupancy Type: I certify that I have read this application and stale 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accme against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-poinl source regulations per the Cupertino Municipal Code.Section 9.18. / Issued by:��/✓ / f/i lif� Date:6 Signature Date ❑ OWNER-BUILDER DECLARATION RE-ROOFS: 1 hereby affirm that 1 am exempt from the Contractor's License Low for one of All roofs shall be inspected prior to any roofing material Meng installed 11'a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for 1,as owner of the property.or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044. Business&Professions Code) Signature of Applicant: Date: I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044.Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR REE-VER 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 IIAZARDOUS MATERIALS DISCLOSURE Compensation,as provided liu by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California I leallh&Safely 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[leallh& Section 3700 of the Labor Code,fiu the performance of the work for which this Safety Code,Section 25532(1)should].store or handle hazardous material. Additionally,should 1 use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Qualim Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the nal employ any person in any nhanncr so as to become subject to the Worker's Ileallh&Safely Code,Sections 25505,25533,and 25534. Cunmpahsationlmvsof Califihmia If after making this certificate of exemption.I become subject to the Worker's Compensation provisions of the Labor Code,I must Owner or au r ed agent: forthwith comply with such provisions or this permit shall be deemed revoked. Dale: I� APPLICANTCERTIFICATION CONSTRIICI'ION LENDING AGENCY certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of hwrk's correct I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address costs,and expenses which may accrue against said City in consequence of the granting oflhis permit Additionally,the applicant understands and will comply with all non-point source all non-point source regulaa is per the Cupertino Municipal Code.Section ARCHITECT'S DECLARATION the Cupertino Municipal Code,Section ARCHIT'F.CT"S DECLARATION 9.18. / 1 understand my plans shall be used as public records. Signature Date 0 �j Licensed Professional CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32651046 . 00 DATE ISSUED. . . . . . . : 06/19/2012 RECEIPT #. . . . . . . . . : BS000017102 REFERENCE ID # . . . : 12060111 SITE ADDRESS . . . . . : 22192 BITTER OAK ST SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : CHAND ADITYA AND RUCHI ADDRESS . . . . . . . . . . : 22192 BITTER OAK ST CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . ADITYA CHAND CONTRACTOR . . . . . . . . LIC # *OWNER* COMPANY . . . . . . . . . . : CHAND ADITYA AND RUCHI ADDRESS . . . . . . . . . . : 22192 BITTER OAK ST CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL --------- ------------- ---------- ---------- ----------' ------- --- - lADMIN HOURS 1 .00 41 .00. 0 .00 41 .00 0. 00 1BCBSC VALUATION 2, 805 .00 1.00 0. 00 1. 00 0. 00 1BREMAIRHA NO.UNITS 1. 00 65 . 00 0. 00. 65 . 00 0. 00 1BSEISMICR VALUATION 2, 805.00 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 VISA --------------- TOTAL RECEIPT 195.50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------- ----- ------- -------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL ► 2z O1I GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 MIS C CUPERTIN0 (408).M-32288�-FAX(408)777-3333•buildino(cD-cuoertino.ota ❑PLUMBING Q rp rMlYMCHAMCAL ❑ELECTRICAL MISCELLANEOUS PROJECT ADDRESS yZ 1 q 2 V �'1 yT6-K - "O/1 K 5r . Aw d OWNER NAME ADIT` pP , I�D PHONE ) Q�J p�I G. 15-ty EMAM STREETADDRESSZ y( 12- I i O' CRY,STALE, C O D '1J a s-DI FAX CONTACT NAME 1 PHONE EMAIL STREET ADDRESS CITY,STATE, ffi FAX OWNER ❑ OWNER.BUBDER 11OWNFRACFNT 13 CONTRACTOR ❑CONTRACTOR AGer ❑ ARCHrracr ❑ENODIEER ❑ DEVELOPER ❑TeIANT CONTRACTOR AME LICENSE NUMBER TYP BUS.LICA COMPANY NAME E-MAIL FAX MEET � �G• t CITY STATE ZIP r f! L G P DV ARQRTECT/PNGINEER NAME ^ /J UC04SE NUMBER BUS.LIC a COMPANY NAME' /�. E.MAJL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF STDwDUPLEX ❑ MULTI-FAMILY PROJECT IN WDDIAND ❑ YES PROJECTW YES IS Tiff BLDG AN El YES BUDDING: COMMERC'LU. URBAN INTERFACE AREA NO FLOOD 20NE NO DCHLER HOME? NO DESCRFTION OF WORX Rf-fl-A-t,f- vjJ(T , 6� F_PL ftt'F- I:v Af f/- TOTAL VALUATION: d�{G, CJG RECETVID BY: By my signature below,I certify to eacli"of the following: I am the propvty owner or authorized agent to act on the property owner's behalf. 1 have Toad this application and the information I have provided is correct 1 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 b(yt1¢)t 1}Ii construed i authorize representatives of Cupertino to enter the above-ideodfiedprope.—./for inspection pui�oses. Signature of ApplicaDVAgeot Ui/il - Date: SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY N OVER.THE-COUNTER ❑ EXPRESS ❑ STANDARD u S ❑ LARGE ❑ MAJOR MEPMacApp_2011.doc revised 0621111 CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION ADDRESS: 22192 Bitter Oak St DATE: 06/19/2012 REVIEWED BY: Sean APN: z i j( —C� BP#: 'VALUATION: $2,805 'TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex PENTAMATION FURN/AC USE: p PERMIT TYPE: At WORKRemove and replace a roof to A/C system Trane XB13 2-ton). SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES A/C Units (<=10K cfm) 1BREMAIR 1 # $65 TOTALS: "ti $65.00 Mech. Plan Check 0.0 hrs $0.00 Plumb. Plan Check Ek".. flan Cbrck Mech. Permit Fee: IMPERMIT Ph,mb. Permit Frr: Flec P,,,mil Other Meeh. Insp. 0.0 hrs $44.00 Other Plumb Imp. Odrer .Eler. lay. Jleeb. bnp. I4r: Plumb. bup.Fre: liter.blip. NOTE: This estimate does not includefees due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School District,etc). These ees are based on the prefindna information available and are only an estimate Contact the De 1 or aildn'l info. FEE ITEMS (l ce Resnhtlion 11-053 E0: 7/1/11) FEE QTY/FEE MISC ITEMS l'lun Chuck Fre: .Supp/. PC Fee PME Plan Check: $0.00 .Supp!. lnsp Fee PME Unit Fee: $65.00 PME Permit Fee: $44.00 Cunsu-uriiun Ta.e: Administrative Fee: (ADMIN $41.00 Work Without Permit? O Yes 0 No $0.00 Adraut ed P6aoung Pies': Travel Documentation Fee: ITRA VDOC $44.00 A Strong Motion Fec: IBSEISMICR $0.50 Select an Administrative Item 131de Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $195.50 $0.00 TOTAL FEE: $195.50 Revised: 06/30/2012 Simplified Prescrip&e Certificate of CompBauce:2008 Residential HVACAllerations CF-IR-ALT-HVAC Climate Zones l and 3-7 SheAddresr: CAP—ATINO CIS EnforcemenrAgemy: - Dar Pandr p: 2-2 2 F O S . 5D 2- . .- 1 Conditioned Duct imtdatiou Eamixtient Tyne List hfai®am Eflidea _ Floor Ates mquireiment Thermostat Padraged Unit r Over 40 ft of ducts Furnace ©AFUE ®COP_, tServed fry sysrmt added or replaced in Setback indoor Col ®Sf:3r7ty IiSPF - 'after olirudyprewa.mm be Condensing Unit oo EER_ ©Resistance ��st tmcondidooed span �k4 Omer ©R 6 (CZ 1.3-5) • 1.Equipmeut Type:Choose the equipment being install if more Ih®ooe_system,use mwthcr CF-I R-ALT•HVAC for each system. 2.11fioimum Equipment ECOcicocfes: 13 SEER.78%'AFUE,,7.7HSPF for typical residential systems. Contractor(Documentation Author's/Responsible Designer's Declaration Statement) • 1 certify that this Certificate of Compliance domm�eoto i®is accurate and complete. • 1 am eligible under Division 3 of the Californin Business and Professions Code to accept responsibility for the design identified con this Certificate of Complisonce: • 1 certify that the energy features and peiiotmance specifications for the design identified on this Certificate of Comphanw conform to the requimnrns of Title 24,Parts I-and,6 of the California Code of Regulations. • The design femurs idemifwdl oathis Certificate of Compliance am consistent with the information documented on other applicable compliance loans,worksheet's,calculations,plans and specifications submitted to the entorovneot agency for approval with the permit application- Name; "ITY0 CAi p Si mtne: Company:CpNTRALTOA;, A'tliEt>', AtRF 'SF—(ZyIC.0 Date: 6 /Q Iz Address: 2 7-142 I TT 6:k O/M ,5 f:t . • vLg ( Lunare: 2 ('0 0 3-5 City/Statetzip: r }C , - Phone: Lf o g 9`71 i . • 2008 Residential Compliance Forms.doc revised 04110112 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228- FAX(408)777-3333- buildinciOCuoenino-ora Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS 022 61"k� APN BP# 1 ` ,1 J OWNER NAMEF OWNER ADDRESS 2-7-(Cj'2 DESCRIPTION OF WORK: We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you,the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.) I understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner- uilder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. I understand building permits are not required to be signed by property owners unless they are responsible for construction and are not hiring a licensed Contractor to assume this responsibility. WI understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may te&ct myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. li 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. 4t­aI 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an"employer"under state and federal law. 6. 1 understand if I am considered an"employer"under state and federal law, I must register with the state and eraI government,withhold payroll taxes, provide workers' compensation disability insurance, and contribute to nemployment compensation for each "employee." I also understand my failure to abide by these laws may subject E'osidential serious financial risk. I understand under California Contractors' Slate License Law, an Owner-Builder who builds single-family structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for y financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship or materials. 0)rne,-BuilderForm ?010doc reriser109/14/10 l I understand I may obtain more information regarding my obligations as an "employer"from the Internal venue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents.•I also understand I may contact the California Contractors'State License Board (CSLB)at 1-800-321-CSLB (2752)or www.csib.ca.gov for more information about licensed contractors. 4�thI am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I e party legally and financially responsible for proposed construction activity at the site address listed above. t 1agree that, as the party legally and financially responsible for this proposed construction activity, I will abide pplicable laws and requirements that govern Owner-Builders as well as employers. Iagree tonotify the issuer of this'form immediately of any additions, deletions,or changes to any of the tion I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does�not have a,license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint.Your only remedy against unlicensed Contractors may be in civil court. Itis also important for you to understand that if an unlicensed Contractor or employee of that individual or firth is injured while working on your property,you may be held liable for damages. If you obtain a permit as Owner-Builder,and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers'compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS:Please complete the following construction lending agency information.) hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit cambe Issued;this form must be completed and signed by the property owner and returned to the agency responsible for Issuing the permit. Note:A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city m be required to be presented when the permit is issued to verify the property owners si nature. Property Owner's Signature: Date: 6 1Z (NOTE: The following Authorization Forrrr is required to be completed by the properly owner only when designating an agent of the property owner to apply fora,construction permit for the Owner-Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner,the execution of which I understand is my personal responsibility, I hereby authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project(or Description of Work): Project Location or Address: rZ?t q,2— W N CA B Name of Authorized Agent: Tel No Address of Authorized Agent: declare under penalty of perjury that l am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city maybe required t be presented when the permit is issued to verify the property owner's signature. / q Property Owner's Signature: Date: OuY]el'Bltilder'FOI'n] 2ol0.doc reriscd 04114/10