10110120I CITY OF CUPERTINO BUILDING PERMIT I
I BUILDING ADDRESS: 21757 MC CLELLAN RD I CONTRACTOR: SANDIUM I PERMIT NO: 10 110 120 J
I OWNER'S NAME: JAHJA AND KRISTINA TRISNADI 14223 VERDIGRIS CIR I DATE ISSUED: 11/18/2010 I
OWNER'S PHONE: 4088949072
LICENSED CONTRACTOR'S DECLARATION
License Class Lic. # '00
Contractor
l
Contractor ,gin, Date ( ( -U ( 0
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:
1. 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.
2. 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
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 so regulations per the Cupertino Municipal Code, Section 9.18.
Signature Date
OWNER -BUILDER DECLARATION
„ereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
i. 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)
2. 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
1 hereby affirm under penalty of perjury one of the following three declarations:
1. 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.
2. 1 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.
3. 1 certify that in the performance of the work for which this permit is issued, 1 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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
sting of this permit. Additionally, the applicant understands and will comply with
ion -point source regulations per the Cupertino Municipal Code, Section 9.18.
Signature Date
SAN JOSE, CA 95134
PHONE NO: (408) 894-9072
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
REPLACE FURNACE AND ADD A/C
Sq. Ft Floor Area: I Valuation: $8900
APN Number: 35719062.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued bye 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 Appl
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, Sections 25505, 25533, and 25534.
07"r thorized ate}
/^ Date: t 2-0(D
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
FM -7 FEE ESTIMATOR -BUILDING DIVISION
APPLIANCE / EQUIP TYPE
Mech.
ADDRESS: 21757 McClellan
DATE: 11/18/2010
REVIEWED BY: building s
UNITS
APN:
BP#: 01/(�)
*VALUATION: $8,900
*PERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
lex
USE:
I ;T ,l1) �
%rfd, e�-
PENTAMATION FURN/AC
PERMIT TYPE:
WORK
residential furnace replacement add A/C.
SCOPE
Suppl, Il tri 1-1v
APPLIANCE / EQUIP TYPE
Mech.
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
'A
Furnace, Forced -Air
1MFR=<100
�_Lj.
1
#
$126
A/C Units (<=10K cfm)
1BREMAIR
Suppl, Il tri 1-1v
1
#
$63
PME Unit Fee:
$189.00
PME Permit Fee:
$42.00
C `orr.�trrrcrruF= '1ir.i
<1t (11!.Stlf'!PI I�c`1'h.'ti I c.'tl:
Work Without Permit? 0 Yes E) No
$0.00
TOTALS:
Travel Documentation Fee: ITRAVDOC
$189.00T-
189.00
Strong Motion Fee: IBSEISMICR
NOTE: These fees are based on the Dreliminary information available and are onlv an estimate. Contact the Dent for addh 7 info.
FEE ITEMS (Fee Resohrtion 0.9-051 Elf. T'1,1 0)
Mech. Plan Check0.0 hrs $0.00
QTY/FEE
MISC ITEMS
Mech. Permit Fee: IMPERMIT
'A
Other Mech. Insp. 0.0 hrs L$42.00
-� ..L
�_Lj.
PME Plan Check:
$0.00
NOTE: These fees are based on the Dreliminary information available and are onlv an estimate. Contact the Dent for addh 7 info.
FEE ITEMS (Fee Resohrtion 0.9-051 Elf. T'1,1 0)
FEE
QTY/FEE
MISC ITEMS
Plat, t'llec A Vc c:
'A
sllpp/PC
PME Plan Check:
$0.00
1'cnnut F"c:
Suppl, Il tri 1-1v
PME Unit Fee:
$189.00
PME Permit Fee:
$42.00
C `orr.�trrrcrruF= '1ir.i
<1t (11!.Stlf'!PI I�c`1'h.'ti I c.'tl:
Work Without Permit? 0 Yes E) No
$0.00
1'lrrttrt�tt,=� l c�:.g:
Travel Documentation Fee: ITRAVDOC
$42.00
Strong Motion Fee: IBSEISMICR
$0.89
Select an Administrative Item
Bldg; Stds Commission Fee: 1BCBSC
$1.00
SUBTOTALS:
$274.89
$0.00 TOTAL FEE:
$274.89
Revised: 11/08/2010
6 ITEMS OF 11
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 35719062.00
DATE ISSUED.......: 11/18/2010
RECEIPT #.........: BS000012039
REFERENCE ID # ...: 10110120
SITE ADDRESS .....: 21757 MC CLELLAN RD
SUBDIVISION ......
CITY .............. CUPERTINO
IMPACT AREA ......
OPERATOR: suew
COPY # : 1
OWNER ............: JAHJA AND KRISTINA TRISNADI
ADDRESS ..........: 21757 MC CLELLAN RD
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
RECEIVED FROM ....: YIU-HANG LEE
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
----------
8,900.00
----------
1.00
----------
0.00
----------
1.00
----------
0.0.0
1BREMAIRHA
NO.UNITS
1.00
63.00
0.00
63.00
0.00
1BSEISMICR
VALUATION
8,900.00
0.89
0.00
0.89
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
----------
274.89
----------
0.00
----------
274.89
0.00
VOICE ID DESCRIPTION
-------- ----------------------------
505 FINAL ELECTRICAL
508 FINAL MECHANICAL
VOICE ID DESCRIPTION
-------- ----------------------------
507 FINAL PLUMBING
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: 5
PERMIT #
OWNER'S NAME:PHONE
# S Qo 7Z -
GENERAL CONTRACTOR: Sa ,,1
BUSINESS LICENSE #
ADDRESS:��
CITY/ZIPCODE:
*Our municipal code requires all busifi�sses 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:
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
Cl OF
CUPERTINO
CITY OF CUPERTINO
FURNACE/AC
PERMIT APPLICATION FORM
APN # . a
Date: I ` /S L2, I
Building Address: 1 7
Owner's Name:%In 'V/ -
Phone #:
Contractor:
Phone #: o 02�S
(,Lvt
Fax #: 64q -
q -ConS
tractor License #:
Contractor
Cupertino Business License #:
Contact:
Phone #: 40�6�o O
_l
Fax #:
Building Permit Info:
Elect. Plumb [ Mech
Residential Commercial ❑
Job Description:
G Ctd1
For Residential Installations: �/
_ 2nd floor ❑
Attic El I' floor -LI
Adhere to minimum setback requirement EJ
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 Constructio�nr( sage Class):
Strapped El On Platform z Bonded New Location Replacement
Project Size: Ex ress �tandard ❑ Large ❑ Major ❑
Valuation:
4�,lOv
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 Ul/U//Uy