11070003 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11107 LINDA VISTA DR CONTRACTOR:TFF HEATING AND AIR PERMIT NO: 11070003
CONDITIONING
OWNER'S NAME: MARK SELDEN 299 CORNING AVE DATE ISSUED:07/01/2011
( :R'S PHONE: 4085682105 MILPITAS,CA 95035 PHONE NO:(408)786-8120
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class a —20 Lic.#
'� 3�� MECH r RESIDENTIAL r COMMERCIAL F
Contractor ti- l a. Date
I hereby affirm tha I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:ADD NEW A/C UNIT(BRYANT 3 TON 13 SEET R-410)
ADHERE TO SFT SETBACK
(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.
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:$3000
permit is issued. CF
APPLICANT CERTIFICATION APN Number:35606019.00 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.
Issued by�"z" .._s--=- Date: -�--��
Signature, � v Date ? Zd
CL 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
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:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Scc.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. 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 Health&
Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this 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 O n r or author' d agent
Date:
forthwith
� � Z d �
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
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
i -mify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
and expenses which may accrue against said City in consequence of the
graoting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with 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
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 11107 linda vista DATE: 07/01/2011 REVIEWED BY: bobs.
APN: BP#: "VALUATION: 1$3,000
y PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Du lex PENTAMATION FURN/AC
USE: p PERMIT TYPE:
WORK add new a/c unit adhere to 5ft setback.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
A/C Units (<=10K cfm) 1BREMAIR 1 # $63
TOTALS: $63.00
Mech.Plan Check0.0 fns $0.00
Mech.Permit Fee: 1MPERMIT -
--LI , LLT --L L
Other Mech.Insp. 0.0 hrs $42.00
NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addh 7 info,
FEE ITEMS (P'ee Resolution 09-051 I f. ','1.-%0) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $63.00
PME Permit Fee: $42.00
"Ie F-1
Work Without Permit? 0 Yes G No $0.00
Travel Documentation Fee: ITRA VDOC $42.00
Strong,Motion Fee: IBSEISMICR $0.50 0.5 hrs Admin./Clerical Fee
Bld�zy Stds Commission Fee: IBCBSC $1.00 $39.00 /ADMIN
SUBTOTALS: $148.50 :$39.00 TOTAL FEE: 1 $187.50
Revised: 04/29/2011
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
.:U P E RTI N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: ( Ar PERMIT#
OWNER'S NAME: r-- LD4_- /�/ PHONE# S
GENERAL CONTRACTOR: —tt>Al e_V Ke_i1 A BUSINESS LICENSE #
ADDRESS: C-orAf jjg, CITY/ZIPCODE: NSM%t A s'
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signa re Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum /Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting /Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contracto gnature Date
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255Lo MISC
(408)777-3228• FAX(408)777-3333• building(aDcupertino.org
CUPERTINO
PLUMBING MECHANICAL ❑ELECTRICAL [:]MISCELLANEOUS
PROJECT ADDRESS I 1 I D� / C(� ' /I S-}-� APN#
OWNER NAME /Vk A?-%�_ SE LL t>F N I
PHONE 5-(0 g—`7 ' E-MAIL
STREET ADDRESS a.S O, `� CITY, STATE,ZIP i1, �J;�� C FAX J�
V
CONTACT NAME �A R1C GPHONE
STREET ADDRESS 1" S� CITY,STATE, ZIP (�C
SA�.�
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR TRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME � (�v,r LICENSE NUMBER I '?S� LICENSE TYPt_ 24) BUS.LIC#
COMPANY NAMETEE
1 EMAIL FAX 9 O `1
STREET ADDRESS A I / (- ��J/� CITY,STATE,fIP d 5 PHONE.LA CIP315 _ _ �'�O
ARCHITECT/ENGINEER NAME` (�'V LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN W ILDLAND ❑ YES PROJECT IN El YES IS THE BLDG AN YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA �O FLOOD ZONE 0�0 EICHLER HOME? -} O
DESCRIPTION OF WORK 14-1 avA4/ 6n S' Te
A- A- r a
S '? L"k-..
/ d�O ��... RECEIVED BY:
TOTAL VALUATION: .7
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 building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection puiposes. "
Signature of Applicant/Agent: Date: -71t2-o
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
OVER-THE-COUNTER
❑ EXPRESS
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❑ STANDARD
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❑ MAJOR
MEPMiscApp_2011.doc revised 06121111