10110169 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10552 JOHNSON AVE CONTRACTOR:AIR QUALITY HEATING PERMIT NO: 10110169
&AIR
'OWNER'S NAME: ALEX LEI 720 NORTHRUP ST DATE ISSUED: 11/24/2010
.,vVNER'S PHONE: 4082937138 SAN JOSE,CA 95126 PHONE NO:(408)293-7138
❑ LICENSEDCONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIAL
LI
License Class Lie.# ' /^ / REPLACE WALL HEATER IN EXISTING LOCATION
Contract o"that
lQate ` �I
I hereby used 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. Sq.Ft Floor Area: Valuation:$1250
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 APN Number:37528035.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 D LAST CALLED INSPE TION.
indemnify and keep h ss t e City of Cupertino against liabilities,judgments,
costs, expenses ich ma accrue against said City in consequence of the j �
grant g of thi i Ad it] ly,the plicant understands and will comply Issued by: Date:
wit all non- o ou re I ns per a Cupertino Munici I Code,Section
9.1
l rl� RE-ROOFS:
cign re Date f� (/ 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.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532( should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,sh use uipm nt or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as deft ed b e a Are it Qu ity Management District I
performance of the work for which this permit is issued. will maintain complian a wi u t' uni pal Code,Chapter 9.12 a d
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Co e,S s2 �i, 25534. f
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized a nt: Date:
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 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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
,)n the above mentioned property for inspection purposes.(We)agree to save
;mnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
,,osts,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 37528035 . 00
DATE ISSUED. . . . . . . : 11/24/2010
RECEIPT #. . . . . . . . . : BS000012091
REFERENCE ID # . . . : 10110169
SITE ADDRESS . . . . . : 10552 JOHNSON AVE
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . . ALEX LEI
ADDRESS . . . . . . . . . . : 10552 JOHNSON AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : AIR QUALITY HEATING
CONTRACTOR . . . . . . . : MATTHEW FARBER LIC # 22791
COMPANY . . . . . . . . . . : AIR QUALITY HEATING & AIR
ADDRESS . . . . . . . . . . : 720 NORTHRUP ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95126
TELEPHONE . . . . . . . . : (408) 293-7138
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 1, 250 .00 1. 00 0 . 00 1 . 00 0. 00
1BSEISMICO VALUATION 1, 250 .00 0 .50 0 .00 0 . 50 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 148 . 50 0 . 00 148 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 148 .50 MC
---------------
TOTAL RECEIPT 148 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10552 johnson ave. DATE: 11/24/2010 REVIEWED BY: bobs.
APN: -7,!5 1 BP#: 0((_,,G/ "VALUATION: 1$1,250
;PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY 7-07'.111' PENTAMATION FURN/AC
USE: SFD or Duplex 7�i r�c?l"AN1.;, PERMIT TYPE:
WORK replace existing wall heater at same location
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Floor 1 # $63
TOTALS: $63.00
Mech.Plan Check 0.0 hrs $0.00
[Mech.PermitFee: IMPERMIT J
Other Mech.Insp. 0.0 hrs $42.00 �;` ,a' '��<, Lj
'A"/' �1:.9i',t, f':2'- F ,rr:31'_ ? rI r A'.
NOTE: Theseees are based on the preliminary information available and are only an estimate. Contact the De t or addn'1 info,
FEE ITEMS(Fee Resolution 09-051 Elf. 7,j.lOj FEE QTY/FEE MISC ITEMS
1/an Chclk
S1fppl, PC 1"ce
PME Plan Check: $0.00
1'cx�r mit Fee:
;Step/. 111.p P"C
PME Unit Fee: $63.00
PME Permit Fee: $42.00
("onstr'trc lion Tax
Work Without Permit? 0 Yes 0 No $0.00
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: $148.501 $0.00 TOTAL FEE: 1 $148.50
Revised: 11/08/2010
st
Community Development
10300 Torre Avenue
Cupertino CA 95014
11 Telephone(408)777-3228
CITY OF Fax(408)777-3333
':UPE�TINO
Building Department
JOB ADDRESS: Ana PERMIT #
OWNER'S NAME: (e. 1 PHONE # —
GENERAL CONTRACTOR: FAX # /\
I am not using any subcontractors: 1 +1 tv
Si ture 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
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF
CITY OF CU
PERTINO L
GENERAL BUILDING
CUPERTINO PERMIT APPLICATION FORM
APN
Building Address:
Mailing Address (if different from buiWin addss):
of
Are Hazardous Materials being used as part of this project? Yes ❑ No
IM: Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA
Owner's Name: n I t� bn ; Phone #: ,/�� D 5- ,.
- !D
Contractor: . `'� � Phone: Q ''j- �j
I „'4 ax:
Contractor License #: q/ ,SIR I I U
Cupertino Business License#:
Contacy�-^ Phone: ,
Fax:
Residential Commercial ❑
Job Description:
Building Permit Info:
Bldg Com' Elect 0- Plumb Mech �`—
Type of Construction (Usage Class): Occupancy Type:
1-A 1-B 0 II/III/V-A ❑ lI/I11 BacT , IV-HT, V-B 0j
Valuatio I Square Footage:
�i ,
Project Size: Express tandard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set& the sheet index.
Points Achieved: —
For help,contact Build it Green at www.builditgreen.org
Revised 07/14/09