10100026 CITY OF CUPERTINO ]BUILDING PERMIT
BUILDING ADDRESS: 10164 S FOOTHILL BLVD CONTRACTOR:SANDIUM PERMIT NO: 10100026
OWNER'S NAME: JOAN THOMPSON 4223 ✓ERDIGRIS CIR DATE ISSUED: 10/04/2010
IER'S PHONE: 4082522910 SAN.IOSE,CA 95134 PHONE NO:(408)894-9072
LICENSED CONTRACTOR'S DECLARATIONF
`�� BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class 70 Lic.#
MECH F RESIDENTIAL r- COMMERCIAL F
Contractor (,(N,�«1 r,.. Date 10
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL NEW FURANCE AC SYSTEM IN ATTIC
(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.F Floor Area: Valuation:$12000
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. APN Number:35701091.00 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 p ERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 D YS FROM L CAL ED INSPECTION.
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 s e regulations per the Cupertino Municipal Code,Section Issu(d by. Date:
9.18. '
Signature Date
RE-ROOFS:
Li OWNER-BUILDER DECLARATION All re ofs shall be inspected prior to any roofing material being installed.If a roof is
instal ed without first obtaining an inspection,I agree to remove all new materials for
I hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I hav:read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safet✓Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Addii ionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. main:ain compliance 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 Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's Ow tTthorized age t II
Compensation laws of California. If,after making this certificate of exemption,I Date:
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. CONSTRUCTION LENDING AGENCY
I here by affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for w rich this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
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 Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
unify 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 I and;rstand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18• Licer sed Professional
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: 'EVALUATION: 1$12,000
*PERMIT TYPE: Mechanical Permit PLAN CI[ECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex l i' PENTAMATION FURN/AC
USE: p �`�' -=_ PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
A/C Units (<=10K cfm) 1sREMAIR 1 # $63
Furnace, Forced-Air 1MFR=<100 1 # $126
TOTALS: $189.00
Mech.Plan Check 0.0hrs $0.001 J
Mech.Permit Fee: IMPERMITI ' Pur- FCC,
Other Mech.Insp. 0.0 hrs $42.00Li
,
NOTE: Thesefees are based on the preliminary information availa 51e and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 09-051 F,ff. 7/1/10) FEE QTY/FEE MISC ITEMS
4'rr,pl,l. PC 1''E
PME Plan Check: $0.00
(1'i:°�trait 1'oc
PME Unit Fee: $189.00
PME Permit Fee: $42.00
( 'L�I75 Z%Cffraf i;t'i
�?k'Vic�i /'c°
Work Without Permit? 0 Yes No $0.00
Travel Documentation Fee: I TRAVD0C $42.00
Strong Motion Fee: $1.20 Select an Administrative Item
Bldg Stds Conunission Fee: IBCBSC $1.00
SUBTOTALS: $275.20 $0.00 TOTAL FEE: $275.20
Revised: 9/29/2010
CITY OF CUEERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35701C91.00
DATE ISSUED. . . . . . . : 10/04/2010
RECEIPT #. . . . . . . . . : BSOOOC11631
REFERENCE ID # . . . : 10100C26
SITE ADDRESS . . . . . : 10164 S FOOTHILL BLVD
SUBDIVISION . . . . . . :
CITY . . . . . . . . . . . . . . CUPERZINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : JOAN ZHOMPSON
ADDRESS . . . . . . . . . . : 10164 S FOOTHILL BLVD
CITY/STATE/ZIP . . . : CUPERgINO, CA 95014
RECEIVED FROM . . . . : YIU-H'CANG LEE
CONTRACTOR . . . . . . . : MICHAEL LEE LIC # 28867
COMPANY . . . . . . . . . . : SANDI'CM
ADDRESS . . . . . . . . . . : 4223 VERDIGRIS CIR
CITY/STATE/ZIP . . . : SAN JCSE, CA 95134
TELEPHONE . . . . . . . . : (408) 894-9072
FEE ID UNIT QUANTITY AMOLNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 12, 000 . 00 1 . 00 0 .00 1 . 00 0 . 00
1BREMAIRHA NO.UNITS 1. 00 63 . 00 0 .00 63 . 00 0 . 00
1BSEISMICR VALUATION 12, 000. 00 1 .20 0 .00 1 .20 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 275 .20 0 .00 275 .20 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 275 .20 VISA
---------------
TOTAL RECEIPT 275 .20
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY
502 FINAL PLUMBING ENERGY 503 FINAL MECHANICAL ENERGY
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
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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: ( S , PERMIT
OWNER'S NAME: SO iAPHONE#
GENERAL CONTRACTOR: ,�� BUSINESS LICENSE #
ADDRESS: '+ 'lp� CITY/ZIPCODE: M4
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INS PECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE --z
.
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
o
Owner/Contractor Signature Date
7 CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO PERNUT APPLICATION FORM
APN # 2610 09 0 Date:
Building Address:
Owner's Name: Phone#..
4�bz
Z;z 2-
Contractor:
Contractor: Phone#: <OLt QO,.7 Z
i
Fax#:
Contractor License#: Cupertino Business License#:
Contact: Phone#: 4L R v 72—
Fax
ZFax #:
Building Permit Info:
Elect Plumb EZ' Mech Er--'
Residential Commercial
Job Description:
For Residential Installations:
Attic g 1't floor ❑ 2nd floor ❑
Adhere to minimum setback requirement [�
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation E
New installation Planning Approval Required ❑
Cost of Project: Type of Construction (Usage Class):
i2,^QID
Strapped On Platform Bonded F1 New Location Replacement
Project Size: Express ❑ Standard ❑ Large ❑ Major❑
Valuation: Vlov 0
Green Building: Please complete relevant portion of tie Green Building Checklist & attach it to the
application or if applicable, include Li plan set & the sheet index.
Revised 01/07/09