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10020078 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 11050 FIRETHORNE DR CONTRACTOR:SANDIUM PERMIT NO: 10020078 OWNER'S NAME: USHA KIKKERI 4223 VERDIGRIS CIR DATE ISSUED:02/16/2010 NER'S PHONE: 4086901249 SAN JOSE,CA 95134 PHONE NO:(408)894-9072 �( LICENSED CONTRACTOR'S DECLARATION IIUILDING PERMIT INFO: BLDG F ELECT I- PLUMB �i�81 �{ License Class azo Lic.# V l MECH F_ RESIDENTIAL r— COMMERCIAL� Contractor ^��""' Date 2 OB DESCRIPTION:FURNACE REPLACEMENT 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 which this permit is issued. Sq.Ft Floor Area: Valuation:$1951 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. APN Number:32344005.00 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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS OM 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 _ A with all non-point source regulations per the Cupertino Municipal Code,Section [ssued by: C Date: 9.18. / /L Signature Date 2 L------ 0- RE-ROOFS: t� 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) 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 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. I 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 maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. 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 Owner or r iz age /l 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 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 rnify 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 2/l(-�(G� CITY OF C:UPERTINO 7 ITEMS OF 15 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk Lot: APN 32364005 . 00 DATE ISSUED. . . . . . . : 02/16/2010 RECEIPT #. . . . . . . . . BSO )0009747 REFERENCE ID # . . . : 10020078 SITE ADDRESS 11050 FIRETHORNE DR SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER USHA KIKKERI ADDRESS 11050 FIRETHORNE DR CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-0444 RECEIVED FROM . . . . : YIU-HANG LEE CONTRACTOR . . . . . . . : MICHAEL LEE LIC # 28867 COMPANY SAI�DIUM ADDRESS . 4223 VERDIGRIS CIR CITY/STATE/ZIP SAIS JOSE, CA 95134 TELEPHONE (4C8) 894-9072 FEE IDUNIT QUANTITY JMOUNT PD-TO-DT THIS REC NEW BAL ------ --------- -------- -- -------- ---------- 1BCBSC---- ---- -- VALUATION 1, 951 .00 1. 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 1, 951 .00 0 . 50 0 . 00 0 . 50 0 . 00 1EPERMITFE FLAT RATE 1 . 00 42 . 00 0 .00 42 . 00 0 . 00 iMPERMITFE FLAT RATE 1 . 00 42 . 00 0 .00 42 . 00 0 . 00 1MRRAA UNITS 1 . 00 63 . 00 0 . 00 63 . 00 0. 00 1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 0042_00 - ---0_00 - --- TOTAL PERMIT 232 .50 0 . 00 232 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 528 .30 VISA --------------- TOTAL RECEIPT 528 . 30 VOICE ID DESCRIPTION VOICE ID DESCRIPTION _ -------- ---------------------------- -- ----------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CUPERTINO FURNACE/AC CUPIT TINO PERMIT APPLICATION FORM APN # __ Date: 2 (� 3 Li Building Address: _ -�r— t� pr Owner's Name: �, Phone#: �' I-Z 4- Contractor: Contractor: Phone#: Sa.,,4 Fax#: Contractor License#: Cupertino Business License#: Contact: Phone#: 44 �5490''?2.-- -kc ham`'' Fax#: Building Permit Info: Elect ❑ Plumb ❑ Mech Residential Commercial ❑ Job Description: �Ldyv� For Residential Installations: Attic ❑ I` floor [✓� 2n floor El Adhere to minimum setback requirement ❑ For Commercial Installations: Replacement same weight ❑ Additional weight(structural calcs) E] Structural Calculations required for new installation ❑ New installation Planning Approval Required ❑ Cost of Project: Type of Construction(Usage Class): 41�C.? 1 Strapped On BondI;d New Location El Replacement Project Size: Express ❑ Standard ❑ Large [] Major❑ Valuation: *05 ( Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, incl ide in plan set & the sheet index. Revised 01/07/09 CITY OF CUPERTINO FURNACEAC CUPEk INO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1MRAPPVNT Residential for the install/relocate/or M replacement of ca appliance vent install & not inc in an appl permit. FURNACE FURN/AC 1PGASRES Residential for ca gas piping system of P 1-4 Outlets 1BPGAS For each gas piping system of 5 or P more per outlet. 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Residential Seismic B 1MECPLNCK Mechanical Plat Check M 1 MFR=<100 Furnace Syst<=:I 00k BTU install or M relocate ea forci;d-air/gravity type furnace/burner, incl ducts/vents attached to suct appliance up to and include 100,000 Btu/h 1 MFRN>100 Furnace S yst> 100k BTU install or M relocate ea forc,-d-air/gravity type furnace/burner, incl ducts/vents attached to such appliance over 100,000 Btu/h 1 EPERMITFEE Electric Permit Fee E / 1MPERMITFEE Mechanical Petmit Fee M 1 PPERMITFEE Plumbing Pear.it P I (Z� �PSI-- 1 TRAVDOC Travel Documentation B —7z—� 1BUSLIC Business License B Community Development 10300 Torre Avenue x ` a Cupertino CA 95014 v Telephone(408)777-3228 CITY OF Fax(408)777-3333 XPEkTINO Building Department JOB ADDRES PERMIT # ic 06a, /'Qolp:� W OWNER'S NAME: ;kkzr, PHO # GENERAL CONTRACTOR: FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSIMISS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Zj-'L�� _ 266 C0 Owner/Contractor Signature Date