11010054 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10145 POTTERS HATCH CMN CONTRACTOR:AAA FURNACE&AIR PERMIT NO: 11010054
CONDITIONING
OWNER'S NAME: ANNA LIN 1712 STONE AVE DATE ISSUED:01/10/2011
ER'S PHONE: 4089212408 SAN JOSE,CA 95125 PHONE NO:(408)2934717
❑ LICENSED CONTRACTOR'S DECLARATION F
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License ClassON; C ZU tic.# —7& $9- 7 / I- I— r
MECH RESIDENTIAL COMMERCIAL
Contractor.^J-T 4 1"y f'A)A-CRS_ Date ��"�d '—t�
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE EXISTING 40 GALLON WATER HEATER,SAME
(commencing with Section 7000)of Division 3 of the Business&Professions LOCATION
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 Sq.Ft Floor Area: Valuation:$1094
Section 3700 of the Labor Code,for the performance of the work for which s
permit is issued. Dy
APN Number:34235049.00 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
to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep s the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses ch cc a against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this p t. A iona ,the applicant understands and will comply
with all in sourc a la' ns per the Cupertino Municipal Code,Section
9.18 r Issued by: Date:
SignatureDate
77
Li OWNER-BUIL DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
I,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, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.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 HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by 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
contaminants as fined by the Bay Area Air Quality Management District I will
permit is issued. mainta' ra ce with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Heal &S ty ode,Sections 25505,25533,and 25534.
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 r o rorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must •�` Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
-mnify 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
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
5 ITEMS OF 25 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 34235049 . 00
DATE ISSUED. . . . . . . : 01/10/2011
RECEIPT #. . . . . . . • • : BS000012441
REFERENCE ID # . . . : 11010054
SITE ADDRESS 10145 POTTERS HATCH CMN
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER ANNA LIN
ADDRESS . . . . . . . . . . : 10145 POTTERS HATCH CMN
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4525
RECEIVED FROM . . . . : RANDO AAA HVAC, INIC
CONTRACTOR . . . . . . . : RANDO, JIM LIC # 8050
COMPANY . . . . . . . . . . : AAA FURNACE & AIR CONDITIONING
ADDRESS . . . . . . . . . . : 1712 STONE AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408) 293-4717
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 1, 094 . 00 1 .00 0 .00 1. 00 0 .00
1BSEISMICR VALUATION 1, 094 . 00 0 .50 0.00 0.50 0 .00
1PPERMITFE FLAT RATE 1.00 42 . 00 0 . 00 42 . 00 0 .00
1PRWHEATR UNITS 1. 00 25.00 0.00 25 . 00 0 .00
1TRAVDOC FLAT RATE 1. 00 42 . 00 0 . 00 42 . 00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 110 .50 0 . 00 110 . 50 0 .00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
------ ---------------------------- ------ ----------------
518 WATER HEATER
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10145 potters hatch commons DATE: 01/10/2011 REVIEWED BY: bobs.
APN: I BP#: *VALUATION: 1$1,094
R*PERMITTYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION PRWHEATR
USE: PERMIT TYPE:
WORK replace water heater at existing location
SCOPE
APPLIANCE I EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Heater 1 PRWHEATR 1 # $25
TOTALS: $25.00
Afc,h. 1,"'O t t`hack Plumb.Plan Check 0.0 hrs $0.00 glee, t hIm(71,,(k
k
t fec;11. Penta I.>c: Plumb.Permit Fee: 1PPERMIT FTt,+c 1'e�rtnit l� �;
other,ttcch. Ins•p- Other Plumb Insp. 0.0 hrs $42.00 Imp, F-1 I
itec{r. Iris]). lee: I'i mIl. li p, 1`ec. Insp- C°co
NOTE: Thesefees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addh 7 info.
FEE ITEMS (Fee Resolution 09-051 Ef'. 7/1%10) FEE QTY/FEE MISC ITEMS
Plan Chi,(-'f(c(,:
sipp/. FCC
PME Plan Check: $0.00
Perinii Fc e:
Silly)/. hisp Fee
PME Unit Fee: $25.00
PME Permit Fee: $42.00
(`onslrlwfion f cLt
tcouslic;cll Rc view
Work Without Permit? 0 Yes 0 No $0.00
t'Icrnrnbz,�r le�es:
Travel Documentation Fee: ITRA VDOC $42.00
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $110.50 $0.00 TOTAL FEE:: $110.50
Revised: 12/07/2010
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: Q 14 5 Pb4 Q,rS a-V-Ch ,&, PERMIT# I 1 C7
OWNER'S NAME: V;n U n PHONE# 4 O Tr - 9-2 1--AqQk-
GENERAL CONTRACTOR A AA —'tA r-A361 BUSINESS LICENSE#
ADDRESS: 11 e /4 41 s h ^�D CITY/ZIPCODE: eCc 9.S lLr
*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:
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/Co actor Signature Date
CITY OF CUPERTINO
WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN# 0 `�' Di t�
Building Address: I O 1 L4 -5 -po t-- A--r--s ++ cc-�c t1 e m rvt dh s
Owner's Name: A,,�)#/.4 1,i A.? Phone#: 4108'
Contractor: 441+ FurNac_e q-- i?anWo HVAC Phone#: 4.00e-993-41-71-7
Fax#: q6 5-- ,-9 g 3 - 67 Y/
Cupertino Business License#: Contractor State License#:
Contact: Dona Gictro eC—Ic4r� �-Ta w Z e r Phone#: L109 -c9-9 3 y
Fax #: gofr -a-93 -6 -7 .1
Building Permit Info:
Bldg Elect El Plumb Mech
Residential []� Commercial ❑
Job Description: Te p I o ce_ 51)ki1D 40 jo l/m-, (occ4e,4� k\.P-4_)tM
Set ry e Uc J, d
Strapped . On Platform Bonded New Location El Replacement
Valuation (cost of project): p 10,�y. o
Project Size: ExpressEl Standarda LargeEl Major
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.
Green Building Points achieved:
Revised 03/10/10