10110005I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 19945 BRENDA CT I CONTRACTOR: SANDIUM I PERMIT NO: 10110005 I
OWNER'S NAME: VERNON MIRANDA 14223 VERDIGRIS CIR I DATE ISSUED: 11/01/2010 I
VNER'S PHONE: 4088949072
0, LICENSED CONTRACTOR'S DECLARATION
License Class --ft 2 O Li,. # f l
�
S < <
Contractor �C 1A(l Date
1 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 which this
permit is issued.
APPLICANT CERTIFICATION f�
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/14 A A—:7n .4.� Date < < J
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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,
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:
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
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 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
i"'emnify and keep harmless the City of Cupertino against liabilities, judgments,
. and expenses which may accrue against said City in consequence of the
-1ting 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.
SAN JOSE, CA 95134
JOB DESCRIPTION: RESIDENTIAL
PHONE NO: (408) 894-9072
REPLACE FURNACE & A/C IN SAME LOCATION
Sq. Ft Floor Area: I Valuation: $8700
APN Number: 36943006.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 PAY.$OF PERMIT ISSUANCE OR
180 DAYS49MM LAST CALLED INSPECTION.
Issued by:
Date: ft
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 I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sectio} 25505, 25533, and 25534. 1 l/ l /j,
Owner or authorized agent: ` Date
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 Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CUPERTINO
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: Y ,A c
57
PERMIT # /0//00057
OWNER'S NAME:
PHONE # 4� gel d 7Z -
GENERAL CONTRACTOR:
BUSINESS LICENSE #
ADDRESS:
CITY/ZIPCODE:
*Our municipal code requires all Ausinesses working in the city to have a City of Cupertino business ncense.
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: / I ( / / to
'gnature Date
Please check applicable subcontractors and complete the following information:
Owner /Contractor Signature
Date
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
6 ITEMS OF 6
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 36943006.00
DATE ISSUED.......: 11/01/2010
RECEIPT #......... BS000011882
REFERENCE ID # ... 10110005
SITE ADDRESS .....: 19945 BRENDA CT
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......
OWNER VERNON MIRANDA
ADDRESS 19945 BRENDA CT
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
OPERATOR: SylviaM
COPY # : 1
RECEIVED FROM ....: SANDIUM
CONTRACTOR .......: MICHAEL LEE LIC # 28867
COMPANY SANDIUM
ADDRESS 4223 VERDIGRIS CIR
CITY/STATE/ZIP ...: SAN JOSE, CA 95134
TELEPHONE (408) 894-9072
FEE ID
UNIT
QUANTITY
AMOUNT
PD -TO -DT
THIS REC
----------
NEW BAL
----------
----------
1BCBSC
-------------
VALUATION
----------
8,700.00
----------
1.00
----------
0.00
1.00
0.00
1BSEISMICR
VALUATION
8,700.00
0.87
0.00
0.87
0.00
1MFR=<100
UNITS
1.00
126.00
0.00
126.00
0.00
1MPERMITFE
FLAT RATE
1.00
42.00
0.00
42.00
0.00
1MRRAA
UNITS
1.00
63.00
0.00
63.00
0.00
1TRAVDOC
FLAT RATE
1.00
42.00
0.00
42.00
----------
0.00
----------
TOTAL PERMIT
----------
274.87
----------
0.00
274.87
0.00
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT :
AMOUNT
---------------
274.87
---------------
274.87
VOICE ID DESCRIPTION
-------- ----------------------------
505 FINAL ELECTRICAL
508 FINAL MECHANICAL
REFERENCE NUMBER
--------------------
VISA
VOICE ID DESCRIPTION
-------- ----------------------------
507 FINAL PLUMBING
CITY OF CUPERTINO
r FF.F. FCTIMATOR — RIIILDING DIVISION
61'
ADDRESS:
DATE: 11/01/2010
REVIEWED BY: gs
UNITS
APN:
BP#:
VALUATION: 1$8,700
PERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
7'07 11,
11 ()OR .z
PENTAMATION FURN/AC
PERMIT TYPE:
WORK
A/C Units (<=10K cfm)
SCOPE
jIpp
ce
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Furnace, Forced -Air
1MFR=<100
1
#
$126
A/C Units (<=10K cfm)
1BREMAIR
jIpp
ce
1
#
$63
PME Unit Fee:
$189.00
PME Permit Fee:
$42.00
Con,�iruufion To,v
Work Without Permit? 0 Yes E) No
$0.00
TOTALS:
Travel Documentation Fee: 1TRAVDOC
1 $189.001
1
X7 T17- Thom %ac nro Ancod nn iho nroliminary infarmatinn availahle and are only an estimate. Contact the Dent for addn'1 into.
FEE ITEMS ("Fee Resolution 09-051 Ef. 7%1/10)
Mech. Plan Check 0.0hrs $0.001
QTY/FEE
MISC ITEMS
Mech. Permit Fee: IMPERMITF!,T_
Other Mech. Insp. 0.0 hrs
F-1
PME Plan Check:
$0.00
X7 T17- Thom %ac nro Ancod nn iho nroliminary infarmatinn availahle and are only an estimate. Contact the Dent for addn'1 into.
FEE ITEMS ("Fee Resolution 09-051 Ef. 7%1/10)
FEE
QTY/FEE
MISC ITEMS
Ph ;i C hck / ec,
slipl"[ J"(" FOC
F71
PME Plan Check:
$0.00
1``r�r//it
jIpp
ce
PME Unit Fee:
$189.00
PME Permit Fee:
$42.00
Con,�iruufion To,v
Work Without Permit? 0 Yes E) No
$0.00
Travel Documentation Fee: 1TRAVDOC
$42.00
Strong Motion Fee: IBSEISMICR
$0.87
Select an Administrative Item
Bldg; Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$274.87
$0.00 Of TOTAL FEE:
$274.87
Revised: 10/17/2010
aC10F
CUPEkTINO
CITY OF CUPERTINO
FURNACE/AC
PERMIT APPLICATION FORM
/0//C-W,f
APN #
Date:
Building Address:
1 Q C' -t
Owner's Name: J y
e�
Phone #: 44 1 01 Z
Contractor:
Phone #: 4,: W 61
Fax #:
Contractor License #:
Cupertino Business License #:
Contact:
Phone #: 4 6,
VVI t�
Fax #:
Building Permit Info:
Elect ❑ -- I Plumb ❑
Mech [,
Residential
Commercial ❑
Job Description: 4 i, .e— kAA
For Residential Installations:
Attic El st floor F-1
2nd 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:Type of Construction (Usage Class):
�37o o
Strapped On Platform Bonded
New Location Replacement
Project Size: Express ❑ Standard ❑ Large ❑
Major ❑
Valuation: -� 0 J
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 01/07/09