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10070041 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21702 LINDYN CONTRACTOR:SANDIUM PERMIT NO: 10070041 OWNER'S NAME: PADMAJA GOGINENI 4223 VERDIGRIS CIR DATE ISSUED:07/06/2010 NER'S PHONE: 4082037093 SAN JOSE,CA 95134 PHONE NO:(408)894-9072 1131. LICENSED CONTRACTOR'S DECLARATION pqq BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Li..# 3Q k` F ,7161(-o' MECH RESIDENTIAL COMMERCIAL Contractor SL IVA �� Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:FURNACE REPLACMENT SAME LOCATION (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:$4500 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:35624035.00 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 PERMIT 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 DAYS FROM LAST CALLED 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 urre regulations per the Cupertino Municipal Code,Section Issued by;_,::f7�� Date: C� 9.18. Signature Date /�/( lJ RE-ROOFS: ❑ OWNER-BUILDER DECLARATION 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 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) I,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 have 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. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,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. maintain 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'sOw r authorized a Compensation laws of California. If,after making this certificate of exemption,I /t.�.,t.., Dater 10 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 hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which 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 anify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date L� CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: DATE: REVIEWED BY: APN: BP#: *VALUATION: $0 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY APPLICATION USE: SFD or Duplex r�1 �� Ir; TYPE: xW as O E 3 . APPLIANCE/EQUIP TYPE CAPACITY FE::ID QTY BP FEES Furnace, Forced-Air 1MFF=<100 1 $126 TOTALS: $126.00 Mech.Plan Check 0.0 1 hrs $0.00 Mech.Permit Fee: IMPERMIT Other Mech.Insp. 0.0 hrs $42.00 NOTE: Theseees are based on the preliminarrTv in ormation G vailable and are only an estimate. Contact the Dept-for addn'1 info. FEE ITEMS (Pee Resolution 09-051 F jf 1;09) FEE QTY/FEE MISC ITEMS PME Plan Check: $(.00 PME Unit Fee: $126.00 PME Permit Fee: $42.00 F71 Travel Documentation Fee: ITRAVDOC $42.00 � r Select an Administrative Item Bldn Stds Commission Fee: $0.00 SUBTOTALS: $210.00 $0.00 TOTAL FEE: $210.00 Revised: 6/30/2010 CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT' RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Bl}:. Lot : APN . . . . . . . . : 35624035 .00 DATE ISSUED. . . . . . . : 07,'06/2010 RECEIPT #. . . . . . . . . : BS000010782 REFERENCE ID # . . . : 10070041 SITE ADDRESS . . . . . : 21'702 LINDYN SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER PADMAJA GOGINENI ADDRESS . . . . . . . . . . : 21'702 LINDYN CITY/STATE/ZIP . . . : CU:?ERTINO, CA 95014 RECEIVED FROM . . . . : YI1J HANG LEE CONTRACTOR . . . . . . . : MICHAEL LEE LIC # 28867 COMPANY . . . . . . . . . . : SANDIUM ADDRESS 42:?3 VERDIGRIS CIR CITY/STATE/ZIP . . . : SAN JOSE, CA 95134 TELEPHONE . . . . . . . . : (4,)8) 894-9072 FEE ID UNIT QUANTITY ;kMOUNTPD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- - --------- ---------- ---------- ---------- 1BCBSC VALUATION 4, 500 . 00 1 . 00 0 .00 1. 00 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 . 00 0 .00 211. 00 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 211 . 00 VISA --------------- TOTAL RECEIPT 211 . 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CUPERTINO FURNACE/AC CU CMO INO PERMIT APPLICATION FORM APN # Date: -7/ ! �i " Building Address:?© �a4AJ, Owner's Name: , Phone#: p �7 G CihA& w O (�evt( ��O La3 (J'3 Contractor: d, at Phone#: /r g � Qo,Z C�,u �,v✓� `-tom Fax#: Contractor License#: Cupertino Business License#: Contact: Phone#: M `C�� � Fax #: Building Permit Info: Elect ❑ Plumb ❑ Mech Residential Commercial ❑ Job Description: f-Wvv,« For Residential Installations: Attic ❑ I` floor 2°d 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): StrappedEl On Platform Bonded New Location F1 Replacement ❑ Project Size: Express ❑ Standard ❑ Large [] Major❑ Valuation: i4-SO D 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 CITY OF CUPERTINO FURPIACE/AC CUPEkTINO FEE S(--'.HEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1MRAPPVNT Residential for the install/relocate/or M replacement of ea appliance vent install &not in cl in an appl permit. FURNACE FURN/AC 1 PGASRES Residential for ea gas piping system of P 1-4 Outlets 1 BPGAS For each gas piping system of 5 or P more per outle". 1BCBSC Cal Bldg Stanc.ards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Residential Se'smic B 1 MECPLNCK Mechanical Pl m Check M 1 MFR=<100 Furnace Syst 100k BTU install or M relocate ea for,ed-air/gravity type furnace/burnei, incl ducts/vents attached to such appliance up to and include 100,00 Btu/h 1MFRN>100 Furnace Syst 100k BTU install or M relocate ea for-,ed-air/gravity type furnace/burnei, incl ducts/vents attached to such appliance over 100,000 Btu/h IEPERMITFEE Electric Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Pennit P 1 TRAVDOC Travel Docurr entation B 1BUSLIC Business Licelse B CITY OF CUPERTINO FURNACE/AC CUPEkTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group AIR FURN/AC CONDITIONING 1BCAIRHAN Commercial A/C Units<= lOk CFM B 1 MCRAA Commercial Mech Repair/alt/add M 1 BCBSC Cal Bldg Standard; Commission Fee B ALL PERMIT TYPES IBSEISMICO Seismic Commerc.al B 1 PGASCOM Commerical for ea gas piping System P 1-4 outlets 1PGASRES Residential for ea ;as piping system P of 1-4 Outlets 1 BPGAS For each gas pip]ng system of 5 or P more per outlet. C:)mm/Resid Jr 1 BREMAIRHAN Residential A/C units<= l Ok CFM B 1 MRRAA Residential Mech Repair/alt/add M 1 BCBSC Cal Bldg Standarc s Commission Fee B ALL PERMIT TYPES IBSEISMICR Seismic Residential B 1 EPERMITFEE Electric Permit E 1 MPERMITFEE Mechanical Perm t M I PPERMITFEE Plumbing Permit P / ITRAVDOC Travel Documentation B IBUSLIC Business License B