11030002CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10142 DENISON AVE CONTRACTOR: THU'S HVAC PERMIT NO: 1103 0002
OWNER'S NAME: LONG NGUYEN
OWNER'S PHONE: 4084460155
j LICENSED CONTRACTOR'S DECLARATION
License Class n Lic. # 0f 2,
Contractor T"d U /�j _Hy4C. Date
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.
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 whin tlys
permit is issued. ( 4A
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
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
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
9.18.
Signature Dale
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1, as owner of the property, or my employees with wages as their sole compensation,
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
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
declarations:
1 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
permit is issued.
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
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
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT'CERTIFICATION
I certify that 1 have read this application and state that the above information is
correct. 1 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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
s, and expenses which may accrue against said City in consequence of the
ting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
2235 RAMISH DR I DATE ISSUED: 03/01/2011
SAN JOSE, CA 95131 ( PHONE NO: (408)839-9241
BUILDING PERMIT INFO: BLDG f— ELECT f— PLUMB f—
MECH RESIDENTIAL COMMERCIAL
JOB DESCRIPTION: REPLACE FURNACE & ADD A/C
Sq. Ft Floor Area: I Valuation: $3500
I APN Number: 31628011.00 I Occupancy Type: I
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued Date:
RE -ROOFS:
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
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District 1
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sect' ns 255J5, a25533Rd 25 34.
Owner or authorized agent: ate: �l
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
rm--7 FEE ESTIMATOR—BUILDING DIVISION
APPLIANCE / EQUIP TYPE
ADDRESS: 10142 denison ave.
DATE: 03/01/2011
REVIEWED BY: bobs.
UNITS
APN:
BP#:
*VALUATION: 1$3,500
xPERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
USE: SFD or Duplex
#
PENTAMATION
PERMIT TYPE: FURN/A ;
WORK
replace exisiting furnace at same location add new A/C unit.
SCOPE
Supp/. I ?sp F cc>
APPLIANCE / EQUIP TYPE
FEE ID
�`�, fit;, , „� � .,
QTY
UNITS
BP FEES
'A
A/C Units (<=10K cfm)
1BREMAIR
1
#
$63
Furnace, Forced -Air
1MFR=<100
Supp/. I ?sp F cc>
1
#
$126
PME Unit Fee:
$189.00
PME Permit Fee:
$42.00
("onsIP°m'Tion Tax
.'.catlir`fc:Ctt 1tF't'!t'ti /`('c'.
Work Without Permit? 0 Yes 0 No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
1 $189.00
Strong Motion Fee: IBSEISMICR
NOTE: These fees are based on the preliminary information available and are onlv an estimate. Contact the Dept for addn 7 info.
FEE ITEMS (Fee Resolution 09-051 Ef. T"Ii10)
Mech. Plan Check F0,01hrs $0.00
�`�, fit;, , „� � .,
n
Mech. Permit Fee: IMPERMIT
'A
Other Mech. Insp.0.0 hrs $42.00
Ll
$0.00
NOTE: These fees are based on the preliminary information available and are onlv an estimate. Contact the Dept for addn 7 info.
FEE ITEMS (Fee Resolution 09-051 Ef. T"Ii10)
FEE
QTY/FEET
MISC ITEMS
'A
slip /. T'("' ["'e
F-1
PME Plan Check:
$0.00
f'c°r-init Fcc:
Supp/. I ?sp F cc>
PME Unit Fee:
$189.00
PME Permit Fee:
$42.00
("onsIP°m'Tion Tax
.'.catlir`fc:Ctt 1tF't'!t'ti /`('c'.
Work Without Permit? 0 Yes 0 No
$0.00
�'jLIt7Pti17<.r I''c'::
Travel Documentation Fee: ITRA VDOC
$42.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$274.50
$0.00 TOTAL FEE:
1 $274.50
Revised: 01 /15/2011
CITY OF
CITY OF CUPERTINO
FURNACE/AC
CUPERTINO PERMIT APPLICATION FORM
//0 3 000:;�--
APN #
Date:
Building Address: `Z ,� � D� Ave-,�'�--
If residential, is house an Eichler? Yes ❑ No ❑ If yes, needs planning approval.
Owner's Name: �f /�(�
Phone #(fig) � 4-6 - 12 / ,6
Contractor: / V�
7 �
Phone #:„� g _ g3 _ �2 A /
Fax #:
z�
Contractor License #: r Z
Cupertino Business License #:
Contact:u j
TI% y A /
Phone #: �p , ;�- z 2
Fax/e-mail:
Building Permit Info:
Elect Q--. Plumb Mech [�
Residential W--*' Commercial ❑
Job Description: // -
J LUG c tV f eA—
/
Dy A 1C -F A ice' A-1 V-T&%f-W\
For Residential Installations:
Attic F-1is'floor El2°d floor ❑
Adhere to minimum setback requirement ❑
For Commercial Installations:
❑
Replacement same weight ❑ Additional weight (structural calcs)
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: cJ �—� -,77�' Type of Construction (Usage Class):
Strapped ❑ On Platform Bonded New Location -EJ ---Replacement
Project Size: Counter D ---Express ❑ Standard ❑ Large ❑ Major ❑
Valuation:
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index.
Revised 12/06/ 1 U
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS: �O 42- � ERMIT # -2^3-- d
OWNER'S NAME: L6 IV & IV 0PHONE # 4-0q 4-t' --67
GENERAL CONTRACTOR: -7Htj 'y-jVAL-C BUSINESS LICENSE #
ADDRESS: br CITY/ZIPCODE: %3
*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 SU CON CTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: ?211 / It
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