11060118 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1089 DERBYSHIRE DR CONTRACTOR:CONDITIONED AIR PERMIT NO: 11060118
OWNER'S NAME: CHOU CHIZEN 1701 LITTLE ORCHARD ST DATE ISSUED:06/14/2011
C' 'ER'S PHONE: 4082912220 SAN JOSE,CA 95125 PHONE NO:(408)291-2220
❑ LICENSED CONTRACTOR'S DECLARATIONa
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License ClLic.# _I�
1 MECH RESIDENTIAL COMMERCIAL
Contractor ,/ 1� Date 1
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:ADD AIR CONDITIONING TO EXISTING FURNACE
(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:$3300
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:36220018.00 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 w'I comply >
with al -point source regulations per the Cupertino Munici 1 Cod Section Issued byr Date C 7 Ct
9.18. \A
Signature Date -l
RE-ROOFS:
L OWNER-BUILDER DECLA ION 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:
1,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: 1 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.
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
permit is issued. maintain compliance with the Cupertino Muni al Co e,Chapter 9.12 and the
Health&Safety Code,Sections 25505,25533,an 2553 .
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'sr o aut orm ent:
Compensation laws of California. If,after making this certificate of exemption,I Date:
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,
and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
L .ng 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
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 36220018 . 00
DATE ISSUED. . . . . . . : 06/14/2011
RECEIPT #. . . . . . . . . : BS000013760
REFERENCE ID # . . . : 11060118
SITE ADDRESS . . . . . : 1089 DERBYSHIRE DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : CHOU CHIZEN
ADDRESS . . . . . . . . . . : 1089 DERBYSHIRE DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : CONDITIONED AIR
CONTRACTOR RICHARD READ LIC # 22334
COMPANY CONDITIONED AIR
ADDRESS 1701 LITTLE ORCHARD ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE (408) 291-2220
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS 0.50 39. 00 0. 00 39.00 0. 00
1BCBSC VALUATION 3, 300 .00 1. 00 0 . 00 1.00 0. 00
1BREMAIRHA NO.UNITS 1 . 00 63 . 00 0. 00 63 .00 0.00
1BSEISMICR VALUATION 3, 300 . 00 0 .50 0. 00 0 .50 0. 00
1MPERMITFE FLAT RATE 1 .00 42 . 00 0 . 00 42 . 00 0. 00
1TRAVDOC FLAT RATE 1 .00 42 . 00 0. 00 42 .00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 187.50 0 . 00 187.50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 187. 50 VISA
---------------
TOTAL RECEIPT 187. 50
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
C U P E RT I N O Telephone: 408-777-3228
CONTRACT R/ SUBCONTRACTOR LIST Fax: 408-777-3333
JOB ADDRESS: 10 PERMIT# d
OWNER'S NAME: PHONE# ocf>
GENERAL CONTRACTOR: �.r
ADDRESS: BUSINESS LICENSE #
CITY/ZIPCODE:
*Our municipal code requires all businesse wo ing in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCC A Y INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR A SUB O RACTORS HAVE OBTAINED A CI Y OP CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
S ature t
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
Sh t ck
Tile
Owner/Contractor Si ture Date
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
MDDRESS: 1089 derbyshire DATE: 06/14/2011 REVIEWED BY: bobs.
PN: I BP#: "VALUATION: 1$3,300 —�
PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY PENTAMATION FURN/AC
USE: SFD or Duplex PERMITXYPE.
WORK add on a/c to exisiting furnace.
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 hrs $0.00 -
Mech.Permit Fee: ]MPERMIT
Other Mech.Insp. 0.0 hrs $42.00 L�j ED
NOTE. These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (P'ee Resolution 09-O51 f;ff. /.-"10) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $63.00
PME Permit Fee: $42.00
Work Without Permit? 0 Yes No $0.00
Travel Documentation Fee: I TRA vDOC $42.00
Strom Motion Fee: 1BSEISMICR $0.50 0.5 hrs Admin./Clerical Fee
Bldg Stds Commission Fee: 1BCBSC $1.00 $39.00 ]ADMIN
SUBTOTALS:L$148.50 r$39.00 TOTAL FEE: $187.50
Revised: 04/29/2011
It (D(C� o ( ( �
GENERAL PERMIT APPLICATION _ MEP
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
Ct1FERt1NC3 (408)777-3228 • FAX(408)777-3333 •tuiiLdrlq@-cup@r In—C-Org MISC
LUMBING 'N CHAMCAL EECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS h ��
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OWNER ,� E-MAIL
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STREET ADDRESS CITY' STATE'ZIP FAX
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STREET ADDRESS CITY,STATE, ZIP FAX
❑OWN ❑ OWNER-HIIILOER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CO&-ZO
RNAME � LI HUS.LIC!!
10-
COMPANY NAME E-bIAII FAX
ARCFUM=IENGINEERNAME LICENSE NUMBER BUS.LIC
COMPANY NAME E-MAIL FAX
STREET ADDRESS are,STATE,Zr? PHONE
OF SFD or Duplex C] Multi-Family PROJECT IN WUMLAND PROJECT IN
srRucruRE: ❑
Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes No
DESCRnMON OF WORK
T V UTION:
d
By my signature below,I certify to ch of th flowing: I am the property owner or authorized agent to act antthee erty owner s hehatf. I have read his
application and the information I hav provide 's orn ct I have read the Description of Work and verify it is aagree to comply with all applicable local
ordinances and state laws rela' to ilding co 'on. I authorize representatives of Cupertino to enter thed tifled property for inspection purposes.
Signature of ApplicandAgent: Date:
SUPPLEMENTAL DIMRMATION REQUMED -
&HFWua4pp_2011.doc revised 03/16/11