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11070188 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10865 W ESTATES DR CONTRACTOR:SANDIUM PERMIT NO: 11070188 OWNER'S NAME: PETER&SUSAN PALUZZI 4223 VERDIGRIS CIR DATE ISSUED:07/26/2011 01*1NER'S PHONE: 4088651930 SAN JOSE,CA 95134 PHONE NO:(408)894-9072 C� LICENSED CONTRACTOR'S DECLARATION p � BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class C710 Lic.# D�` 1 MECH f— RESIDENTIAL COMMERCIAL Contractor �(j(�Qi�c.�w� Date Z I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:AIR CONDITIONING ADDED TO EXISTING FURNACE& (commencing with Section 7000)of Division 3 of the Business&Professions COIL Code and that my license is in full force and effect. ADHERE TO 5'SETBACK REQUIREMENT 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. 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 Area: Valuation:$3500 permit is issued. APPLICANT CERTIFICATION APN Number:36923041.00 Occupancy Type: 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 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 accrue 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-point source regulations per the Cupertino Municipal Code,Section 9.18. Signature �� Date Z 2I A Issued Dat . 2G r OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,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: 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(See.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I 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 Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality 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 not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,I must Owne rrthorized ag / forthwith comply with such provisions or this permit shall be deemed revoked. Date: 7 APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I 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 work'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 c- - and expenses which may accrue against said City in consequence of the ng of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION wi..i all non-point source regulations per the Cupertino Municipal Code,Section 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36923041. 00 DATE ISSUED. . . . . . . : 07/26/2011 RECEIPT #. . . . . . . . . : BS000014187 REFERENCE ID # . . . : 11070188 SITE ADDRESS . . . . . : 10865 W ESTATES DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : PETER & SUSAN PALUZZI ADDRESS . . . . . . . . . . : 10865 W ESTATES DR CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4537 RECEIVED FROM . . . . : YIU-HANG LEE CONTRACTOR . . . . . . . : MICHAEL LEE LIC # 28867 COMPANY . . . . . . . . . . . SANDIUM ADDRESS . . . . . . . . . . : 4223 VERDIGRIS CIR CITY/STATE/ZIP . . . : SAN JOSE, CA 95134 TELEPHONE . . . . . . . . : (408) 894-9072 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 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 VISA --------------- TOTAL RECEIPT 195.50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10865 w. estates dr. DATE: 07/26/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$3,500 PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION FURN/AC USE: PERMIT TYPE: WORK sfd add a/c unit adhere to 5ft setback requirement. 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 Mech.Permit Fee: IMPERMIT Other Mech.Insp. 0.0 hrs $44.00 " NOTE: Thesefees are based on the prelindnaty information available and are only an estimate. Contact the De t or addh 7 info, FEE ITEMS (Eee Resolution I1-053£ff, 7,4,"11) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $65.00 PME Permit Fee: $44.00 Work Without Permit? 0 Yes No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 Strom Motion Fee: IBSEISMICR $0.50 =hrs Admin./Clerical Fee Bldg Stds Commission Fee: IBCBSC $1.00 $41.00 ]ADMIN SUBTOTALS: $154.50 $41.00 TOTAL FEE: $195.50 Revised: 07/04/2011 s . GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 CUPERT{NO (408)777-3228• FAX(408)777-3333• building a..CUDertino.org misc [UMBING 2/MECHANICAL LECTRICAL OMISCELLANEOUS PROJECT ADDRESSS a s+otet 1)r . APN L3' � - )1�3 a L OWNER NAME D �SCX14 Y aL�t PHONE OS Q/ I Gi 30 E-MAIL STREET ADDRESS r 4 CITY, STATE,ZIP D b 1 l FAX Sc�.rc- �.s vo°eco CONTACT NAME V � � PHONE 4 � o Q( 7 HS p E MAII STREET ADDRESS CITY,STATE, ZIP bFAX ❑ OWNER ❑ OWNER-13=FR ❑ OWNER AGENT J2'CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT El ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME � LICENSE NUMBERgn S LICENSE TY?E BUS.LIC# COMPANY NAME E-MAIL as FAX M'Wee2@ Sao, cow+ STREET ADDRESS /{ r ^Ot/1- CITY,STATE,ZIP J � f [' PHONE `{I,'X107•L ARCHITECT/ENGINEER NAME �J LICENSE NUMBER jA 7 BUS.L1C�#CQ b COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE JSE OF SFD or DUPLEX ❑ MULTI-FAMII Y PROSECT IN WII DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA 01NO FLOOD ZONE _15-NO EEI�CHLEERR HOME? �O DESCRIPTION OF WORK Q ( is Q � _eC GlY couG. 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 read this application and the information I have provided is correct.: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 build onstruction; I au representatives of Cupertino to enter the above-ide�d pro erty for inspection pu{poses. Signature of Applicant/Agent: Date: z SUPPLEMENTAL INFORMATION QUIRED OFFICE USE ONLY W OCI VER-THE-COUNTER ❑ EXPRESS :s U W ❑ STANDARD U ❑ LARGE ❑ MAJOR 1 EPMIscApp_2011.doc revised 06121/11