10110126 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 819 KIM ST CONTRACTOR:AAA FURNACE& PERMIT NO: 10110126
AIR CONDITIONING
VNER'S NAME: MR&MRS PANN 1712 STONE AVE DATE ISSUED: 11/18/2010
OWNER'S PHONE: 4088619435 SAN JOSE,CA 95125 PHONE NO:(408)2934717
LICENSED CONTRACTOR'S DECLARATION I r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Classes Zu Lic.# 7 1
''nn MECH RESIDENTIAL COMMERCIAL
�t
Contractor 13 t+ PL-t i/Ja � Date ( I /rs /� JOB DESCRIPTION:REMOVE AND REPLACE FURNACE IN SAME LOCATION
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 whichthis permit is issued. Sq.Ft Floor Area: Valuation:$4583
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 w ;h APN Number:35920003.00 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 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harm ss the City of Cupertino against liabilities,judgments,
costs,and expenses4h ,y accrue against said City in consequence of the Issued b
granting of this p frit:'1, itionally,the applicant understands and will comply Y� Date:
with all non-poi t soul egulations per the Cupertino Municipal Code,Section
9.18. '�
RE-ROOFS:
Date ( ` —�� All roofs shall be inspected prior to an roofing material ben installed.If a roof is
,nature sP P Y g g
�- 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(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment (devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the B Area it Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the perti Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,
(S ns 505 33,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:
permit is issued.
1 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 CONSTRUCTION LENDING AGENCY
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 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
building construction,and hereby authorize representatives of this city to enter
m the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
i:idemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,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 26 PERMIT RECEIPT OPERATOR: bethe
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35920003 . 00
DATE ISSUED. . . . . . . : 11/18/2010
RECEIPT #. . . . • • • . . : BS000012044
REFERENCE ID # . . . : 10110126
SITE ADDRESS . . . . . : 819 KIM ST
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER MR & MRS PANN
ADDRESS . . . . . . . . . . : 819 KIM ST
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4322
RECEIVED FROM . . . . : AAA FURNACE
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 4, 583 .00 1 . 00 0 .00 1 . 00 0 .00
1BSEISMICR VALUATION 4, 583 .00 0 .50 0 .00 0 .50 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
1TRAVDOC FLAT RATE 1 .00 42 . 00 0 .00 42 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 211 .50 0 . 00 211 .50 0 .00
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
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS: '6) "i PERMIT#
OWNER'S NAME: r PHONE# 4/3
GENERAL CONTRACTOR: 14BUSINESS LICENSE #
ADDRESS: 7/Z 4 ,14) &-6 CITY/ZIPCODE:�/-r! -;X
*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:
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/C =actor Signature Date
CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN # 35t O 3 Date:a oo
Building Address: ect,
Owner's Name: Phone #:
Contractor: f,_ C Phone#:
Fax #:
Contractor License#: Cupertino Business License#:
Contact: Phone #:Lf(; - �� _ y .7
Fax #: z4t;S
Building Permit Info:
Elect ❑ Plumb ❑ Mech D",
Residential Er Commercial
Job Description: i1 i C-�'� �c S�i) �:C�► K16 Cc CA 1 ti� �' 10 �/ � ��.� C`��
For Residential Installations:
Attic ❑ I" floor 2nd floor ❑
Adhere to minimum setback requirement [a'
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: $ 5 -� / Type of Construction (Usage Class):
Strapped On Platform Bonded New Location Replacement
Project Size: Express ❑ Standard ❑ Large ❑ Major ❑ _
Valuation: 9/4- , ss � , ("
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