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11080128 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18830 TILSON AVE CONTRACTOR:AIR AND PLUMBING PERMIT NO: 11080128 SYSTEMS OWNER'S NAME: LAI TZE LEUNG TRUSTEE&ET AL 285 SOBRANTE WAY STE P DATE ISSUED:08/16/2011 ER'S PHONE: 6507767986 SUNNYVALE,CA 94086 PHONE NO:(408)733-2000 ❑ LICENSED CONTRACTOR'S DEGLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Clas r Lia C� / MECH r RESIDENTIAL COMMERCIAL .1 Contractor �` GX t t Gi K ?i Date Q(: /�I L, JOB DESCRIPTION:REPLACE FURNACE&AC UNIT I 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. 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.Ft Floor Area: Valuation:$4380 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 APN Number:37516048.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 D FROM LAST CALLED INSPECTION. costs,and expenses which may accrue„against said City in consequence of the granting of this permit. Additionally he applicant understands and will comply with all non-point source regula i per the Cupertino Municipal Code,Section Issued by: Date: 9.18. ////11 Signature Date RE-ROOFS: Li OWNER UI R DECLARATION All roofs shall be inspected prior to any roofing material berg installed.[f a roof is installed without first obtaining an inspection,I agree to remove all new materials for I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following 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) 1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A”OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. 1 have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will maintain compli'Fifice with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safe Code,Sections 25505,25533,and 25534. 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 Owner or iced agent: ` Compensation laws of California. If,after making this certificate of exemption,I Date: ��/v become subject to the Worker's Compensation provisions of the Labor Code,I must I / forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of Hork's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save mify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 37516048. 00 DATE ISSUED. . . . . . . : 08/16/2011 RECEIPT #. . . . . . . . . BS000014465 REFERENCE ID # . . . : 11080128 SITE ADDRESS 18830 TILSON AVE SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER LAI TZE LEUNG TRUSTEE & ET AL ADDRESS 18830 TILSON AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : SERHIY BUKIN CONTRACTOR AIR AND PLUMBING SYSTEMS LIC # 31732 COMPANY . . . . . . . . . . : AIR AND PLUMBING SYSTEMS ADDRESS . . . . . . . . . . : 285 SOBRANTE WAY STE P CITY/STATE/ZIP . . . : SUNNYVALE, CA 94086 TELEPHONE . . . . . . . . : (408) 733-2000 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 4, 380 .00 1. 00 0. 00 1 .00 0 .00 1BREMAIRHA NO.UNITS 1 .00 65. 00 0 . 00 65 . 00 0 . 00 1BSEISMICR VALUATION 4, 380 . 00 0 .50 0.00 0 .50 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 ------000 ---------- ---------- TOTAL PERMIT 325 .50 0. 00 325 .50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- ------------- CREDIT CARD 325 . 50 VISA --------------- TOTAL RECEIPT 325 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- - 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL //a 01,4 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333• building(cDcupertino.org CUPERTINa ❑NEW CONSTRUCTION ❑ ADDITION ❑ TERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# n PROJECT ADDRESS a e? 7 ✓ Y I � r APN# h / �j`�� HO MAIL OWNER NAME �f Zj� `1�(�) STREET ADDRESS / A�L� C 1))� rte! CITY, STATE,ZIP e :M 6) FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR 1:3 CONTRACTOR AGENT ❑ ARCHITECT 101ENGINEER 101DEVELOPER ❑ TENANT CONTRACTOR NAME rrLICENSE NUMBER � ��//` LICENSE TYP BUS.LIC# G n COMPANY NAMEA E-MAIL FAX STREET ADDRESS In l�. CITY,STATE,ZIP fPHONE ARCHITECT/ENGINEER NAME CCC�JJ LI ENSE NUMBER C BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK �j /) i? �� /� Q 11L G I EXISTING USE PROPOSED USE CONSTR TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET.AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETAACH #DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES BEING ADDED? []NO ADDITION? []NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: T . PLANNING APPL# []NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO By my signature below,I certify to each of the following: I am e pr perry owner or authorized agent to act on the prpperty owner's behalf I have read this application and the information I have provided is correct. I e r the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building constructio aut ze representatives of Cupertino to enter the above-idej r 7 r}s�ieCt' n purposes. Signature of Applicant/Agent: Date: / SUPPLEMENTAL INFORMAT O PLAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building ❑ EXPRESS ❑ PLANNING PLAN REVIEW permit for new building. _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ElPUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_201 1.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION JJADDRESS: 18830 TILSON AVE DATE: REVIEWED BY: PN: BP#: "VALUATION: 1$4,380 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY PENTAMATION FURN/AC USE: SFD or Duplex PERMIT TYPE: WORK REPLACE A/C&FURNACE SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES A/C Units (<=10K cfm) 1BREMAiR 1 # $65 Furnace, Forced-Air 1MFR=<100 1 # $130 TOTALS: $195.00 Mech.Plan Check "00 $0.00 FMech.Permit Fee: IMPERMIT Other Mech.Insp. 0.0 hrs $44.00 NOTE: Thesein-fees are based on the preliminaryin ormation available and are onlyan estimate. Contact the De t or addn'1 o. FEE ITEMS (Fee Resolution 11-053 E . 7/1'11) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $195.00 PME Permit Fee: $44.00 Work Without Permit? 0 Yes E) No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 Strong Motion Fee: IBSEISMICR $0.50 0.5 hrs Admin./Clerical Fee Bldg Stds Commission Fee: IBCBSC $1.00 $41.00 1ADMIN SUBTOTALS: $284.50 $41.00 TOTAL FEE: $325.50 Revised: 07/04/2011