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10060108
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21911 HERMOSA AVE CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO: 10060108 DATE ISSUED:06/17/2010 OWNER'S NAME: JAN FELDMAN PHONE NO: NER'S PHONE: 4082574213 ' LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT 1— PLUMB r License Class CZ d __ Li,.# ? 0 o Y MECH f- RESIDENTIAL COMMERCIAL Contractors Uic-e�`-� 01)DI �5 Date U -/7- JOB DESCRIPTION: REPLACE FURNACE&A/C SPLIT SYSTEM I hereby affirm that'I am licensed under the provisions of Chapter 9 **SE];NOTES** (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. Valuation:$9400 I have and will maintain Worker's Compensation Insurance,as provided for by Sq.I t Floor Area: Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APT Number:35716136.00 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 saveWITHIN 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 source regulations per the Cupertino Municipal Code,Section Date: 9 18 Isst ed by: Signature %� ✓ Date RE-ROOFS: U OWNER-BUILDER DECLARATION All -oofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of instilled without first obtaining an inspection,I agree to remove all new materials for the following two reasons: insl ection. I,as owner of the property,or my employees with wages as their sole compensation, Date: will do the work,and the structure is not intended or offered for sale(Sec.7044, Sig iature of Applicant: 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 and will maintain a Certificate of Consent to self-insure for Worker's I h xve read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Sa'ety Code,Section 25532(a)should I store or handle hazardous material. Ac ditionally,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 co utaminants as defined by the Bay Area Air Quality Management District I will permit is issued. in,intain 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 H(alth&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's w p }� Ii/1Il.tl -�✓ e .� Compensation laws of California. If,after making this certificate of exemption,I q, d 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 APPLICANT CERTIFICATION I 1 ereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is fo-which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating L,�nder's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save L mder's Address mnify 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 with all non-point source regulations per the Cupertino Municipal Code,Section I mderstand my plans shall be used as public records. 9.18. ^ (� _ J �� ham-, /_/•�'( � Licensed Professional Signature /�-e. ;(,�.�'� Date ( t1 CITY Of CITY OF C UPERTINO lug FURNACE/AC C U P E RT I N O PERMIT APPLICATION FORM Date: /'_ _� (-(C) Building Address: (L° -�2lc(l( `-l2/woSci- ou- Owner's Name: Phone#: J'a P1 r�ldmay0 zs' -Yu Contractor: S esu ��? C!Gl a ��uv� 5 Phone#: o t o P4 m elc e 17/^ 9 L 5- 9 4 ifsY Fax#: Contractor License#: Cupertino Business License#: 9 l yoq v Contact: Phone#: Rz!�7 Fax#: Building Permit Info: Elect❑ 4Plumb ❑ Mech Residential YJ4 ommercial Job Description: For Residential Installations: Attic ❑ 0 floor ❑ 2 n floor ❑ Adhere to minimum setback re uirement 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): Strapped On Platform Bonded New Location Replacement Project Size: Ex ress ©Standard ❑ Large❑ Major❑ Valuation: Green Building: Please complete relevant portion of the Green Building Checklist& attach it to the application or if applicable,include in flan set&the sheet index. Revised 01/07/09 CITY OF CL PERTINO FEE ESTIMATOR- BUILDING DIVISION JI[AADDRESS: 21911 hermosa avenue SATE: 06/17/2010 REVIEWED BY: building PN: BP#: *VALUATION: J$9,400 PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY r`; APPLICATION USE: SFD or DuplexF .f TYPE: as rpplace furnace/AG split systern 00 3 � APPLIANCE/EQUIP TYPE CAPACITY FEE IT, QTY BP FEES A/C Units (<=10K cfm) 1BREMA R 1 $63 Furnace, Forced-Air 1MFR=<100 1 $126 TOTALS: $189.00 Mech.Plan Check 0.0 1 hrs $0.00 ? Mech.Permit Fee: IMPERMIT . < Other Mech.Insp. 0.0 hrs $42.00 _ r; NOTE. Theseees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS (F'(,e Resolution 09-051 Eff.' T-1%09) FEE QTY/FEE MISC ITEMS 'i, t . PME Plan Check: $0.00 PME Unit Fee: $189.00 PME Permit Fee: $42.00 Travel Documentation Fee: ITRA VDOC $42.00 _; :flSelect an Administrative Item Bldt_, Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $274.001 $0.00 TOTAL FEE: $274.00 Revised: 5/27/2010 CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: :,ot: APN 35716136 .00 DATE ISSUED. . . . . . . : 06/17 /2010 RECEIPT #. . . . . . . . . BS000 )10655 REFERENCE ID # . . . : 10060L08 SITE ADDRESS . . . . . : 21911 HERMOSA AVE SUBDIVISION . . . . . . CITY CUPER'PINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . . JAN FE"LDMAN ADDRESS 21911 HERMOSA AVE CITY/STATE/ZIP . . . : CUPERrINO, CA 95014 RECEIVED FROM . . . . : IE INC CONTRACTOR TBD - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 9, 400 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BREMAIRHA NO.UNITS 1 . 00 63 . 00 0 . 00 63 . 00 0 . 00 1BUSLIC FLAT RATE 1. 00 114 . 00 0 . 00 114 . 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 388 . 00 0 .00 388 . 00 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 388 . 00 43472 --------------- TOTAL RECEIPT 388 . 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 203 UNDERFLOOR MECHANICAL 303 ROUGH MECHANICAL 503 FINAL MECHANICAL ENERGY 508 FINAL MECHANICAL Building Department City Of Cupertino Is 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: /fU-e- PERMIT# /'%':� OWNER'S NAME: PHONE # qZ-3 GENERAL CONTRACTOR: �� 1011 S BUSINESS LICENSE# ADDRESS: Z(}7Zv C.&M04-erG�P_ PC I CITY/ZIPCODE: fk,�1-:0-n t)/,l 'q- Oss i *Our municipal code requires all businesses working in the oity 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: -N '"�" � 6 -17- `� Signature Date Please check applicable subcontractors and complete t le following information: SUBCONTRACTOR BUSINESS 1\AME 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