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11070205 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19766 VICKSBURG DR CONTRACTOR:A&H HEATING PERMIT NO: 11070205 OWNER'S NAME: ALI SIDDIQUI 770 CHESTNUT ST DATE ISSUED:07/27/2011 OWNER'S PHONE: 4082576146 SAN JOSE,CA 95110 PHONE NO:(408)279-0722 [r LICENSED CONTRACTORS DECLAR/AATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class zs"/ Lic.# J� -/ 7 ��Z 7 �� MECH� RESIDENTIAL f COMMERCIAL f Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE FURNACE ADD A/C UNIT (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:$9890 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 permit is issued. APN Number:36910008.00 Occupancy Type: 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 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Issued by �/2--"� Date: 2 9.18. Signature Date 2 / RE-ROOFS: r OWNER-BUILDER DECLARATION 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 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) I,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. 1 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. I 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 compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. 1 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 ner or authorized a& J *�G -7 Compensation laws of California. If,after making this certificate of exemption,1 Date: ` l (( become subject to the Worker's Compensation provisions of the Labor Code,I must 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 work'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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, cn-rc,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION .ng of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. w._ .all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 36910008 . 00 DATE ISSUED. . . . . . . : 07/27/2011 RECEIPT # . . . . . . . . . BS000014206 REFERENCE ID # . . . 11070205 SITE ADDRESS . . . . . : 19766 VICKSBURG DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : ALI SIDDIQUI ADDRESS . . . . . . . . . . : 19766 VICKSBURG DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : D. PHELPS CONTRACTOR . . . . . . . : PHELPS, DALE LIC # 12079 COMPANY . . . . . . . . . . : A & H HEATING ADDRESS . . . . . . . . . . : 770 CHESTNUT ST CITY/STATE/ZIP . . . : SAN JOSE, CA 95110 TELEPHONE . . . . . . . . : (408) 279-0722 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 9, 890 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 9, 890 . 00 0 . 99 0 . 00 0 . 99 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 1MRRAA UNITS 1 . 00 65 . 00 0 . 00 65 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 284 . 99 0 . 00 284 . 99 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 284 . 99 VISA --------------- TOTAL RECEIPT 284 . 99 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST �7 JOB ADDRESS: 7 � V C �-� Z PERMIT# t OWNER'S NAME• Q 1 CPHONE # 77—Z GENERAL CON A R: #L/ 51 1 BUSINESS LICENSE # ADDRESS: C; C f' lj ( CITY/ZIPCODE: 57r-6�,r -��t 9S-11Z) *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: - Signature Date Please check applicable subcontractors and complete the following information: V 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/Contractor Signature Date 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 r(JcuDertino.org misc E]PLUNBING �NIECHANICAL QELECTRICAL ❑MISCELLANEOUS PROTECT ADDRESS /Q-]/ (�, i / /Li/ o L APN# 3taq i. OWNERNAMEC t � PHONE - E-MAIL STREET ADDRESS ( Q 71-/ ��C��/+ CITY, STAUT 7"(5= ^ ' FAX CONTACT NAME / j F/ `_r J� PHONE(q �7 7Z Z. STREET ADDRESS CL� ` CITY,STATE, ZIP — FAX ❑ OWNER ❑ OWNER-BUILDER ( ❑ OWNER AGENT elINTIACTOR ❑CONT?ACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CO CTO&NLICENSE NUMB r LICENSE TYP BUS.LIC# Z COMPANY NAME � _ E-MAILAA4()h#� FAX Art A14- STREET ADDRESS C ! _S CITY,STATE,ZIP` C� �! PHONE Cff� 7'At lT J�dU ...::1—�J991 rJ(�j ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE JSE OF ❑SFD or DUPLEX ❑ MULTI-FAMMY PROJECT IN WILDLAND ❑ YES PROJECT rN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK WI"c ( C F P A I 1 TOTAL VALUATION: RECEIVED BY: J By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the pr perty owner's behalf. I have read this application and the information I have provided is correct.j 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 construction:I authorizr<preVmtatives of gup rtino to enter the above-identified property for inspection pu{poses. Signature of Applicant/Agent: J Date: -7- 2- 7- 1 ( SUPPLEMENTAL INFORMATION REQUUZED OFFI--CE USE ONLY l--OVER-THE-COUNTER c ❑ EXPRESS U U w ❑ STANDARD U ❑ LARGE ❑ MAJOR MEPMiscApp_2011.doe revised 06/21/11