10010003 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21890 CORTE MADERA LN CONTRACTOR:BLUE MOUNTAIN AIR PERMIT NO: 10010003
OWNER'S NAME: DORIN DEBORAH 707 ALDRIDGE RD STE B DATE ISSUED:01/04/2010
VER'S PHONE: 4088922499 VACAVILLE,CA 95688 PHONE NO:(707)451-8111
C( LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB F—
i
License Class gr C 2.D ')'341613 Lic.# J / 96(c,q f— -
MECH RESIDENTIAL COMMERCIAL
Contractor e 2�" JO
I hereby affir hat I licensed un er the provisions of Chapter 9 JOB DESCRIPTION:REPLACEMNT OF FURNACE,AC UNIT,&50 GAL WATER
(commencin it
Semon 7000)of Division 3 of the Business&Professions HEATER.80,000 BTU 95%EFFICIENCY,4 TONAGE&13
SEER RATING
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.
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 Sq.Ft Floor Area: Valuation:$6700
permit is issued.
APPLICANT CERTIFICATION APN Number:32645038.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. �' ty
"�
l Issued ty_;_ ___ Date:..._._� _–� ..w_...�._W_._
Signature Date 1 T /0
V
OW14R-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
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 Owner r aut rize nt:
forthwith comply with such provisions or this permit shall be deemed revoked. ate: J
711,_U
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
unify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
,and expenses which may accrue against said City in consequence of the
g,anting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-poin source re ations per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Signature Date U Licensed Professional
CITY OF
CITY OF CUPERTINO
FURNACE/AC
C U P S RT I N O PERMIT APPLICATION FORM
APN# Date:
ce 5-b -3 c> q 10
Building Address: 218 9 0 CORTE MADERA LA
Owner's Name: DEBORAH DORIN Phone#: 408-892-2499
Contractor: BLUE MOUNTAIN AIR, INC. Phone#: 707-451-8111
Fax#: 707-446-7026
Contractor License#: 398668 Cupertino Business License#:
Contact: REBECCA Phone#: 707-451-8111
Fax#: 707-446-7026
Building Permit Info:
Elect ❑ Plumb E Mech Q
Residential Q Commercial ❑
Job Description: REPLACEMENT OF FURNACE, AC UNIT, AND 50 GALLON WATER HEATER. 80,000 BTU/95% EFFICIENCY,
4 TONAGE AND 13 SEER RATING.
For Residential Installations:
Attic ❑ 1St floor Q 2"d floor 1:1
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 Re wired ❑
Cost of Project: Type of Construction (Usage Class):
B,C20,C36,C43
Strapped On Platform Bonded New Location Replacement x
Project Size: Ex ress ❑ Standard 0 Large❑ Major❑
Valuation:
$6,700
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
FURNACE/AC
CIT%XPEY TING FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
FURNACE FURN/AC
1 MCRAA Commercial-Repair/Alteration/Add to M
ea heating appliance,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,absorption or
evaporative cooling system,incl
installation of controls regulated by this
code.
1 MCREPALT Commercial for the repair of alt/add to M
ea heating appliance,refrigeration
unit,cooling unit,VAV boxes,
absorption unit or ea heathing, cooling
absorption,or evaporative cooling sys,
incl install of controls regulated by
this code.
1 MCSUSHTR Commercial Install/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted unit heater.
1 PGASCOM Commerical for ea gas piping System P
1-4 outlets
1 BPGAS For each gas piping system of 5 or P
more per outlet.
1 MCAPPVNT Commercial for the install/relocate/ or M
replacement of ea appliance vent
installed & not incl in an appliance
permit.
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1 BSEISMICO Commercial Seismic B
1 MRRAA Residential Repair/Alteration/Add to M
ea heating appliance,refrigeration unit,
cooling unit,absorption unit,or ea
f
heating,cooling,absorption or
evaporative cooling system,incl
installation of controls regulated by
this code.
1 MRSUSHTR Residential Install/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted unit heater.
CITY OF CUPERTINO
t: FURNACE/AC
CUPS OF
FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1 MRAPPVNT Residential for the install/relocate/ or M
replacement of ea appliance vent
install & not incl 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 outlet.
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1 BSEISMICR Residential Seismic B
1 MECPLNCK Mechanical Plan Check M
1MFR=<100 Furnace Syst<=100k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance up to and
include 100,000 Btu/h
1 MFRN>100 Furnace Syst> l 00k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance over
100,000 Btu/h
1 EPERMITFEE Electric Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit P
1 TRAVDOC Travel Documentation B
1 BUSLIC Business License B
CITY OF CUPERTINO
l FURNACE/AC
CUPS OF
FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
AIR FURN/AC
CONDITIONING
1 BCAIRHAN Commercial A/C Units<= I Ok CFM B
1 MCRAA Commercial Mech Repair/alt/add M
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1 BSEISMICO Seismic Commercial B
1 PGASCOM Commerical for ea gas piping System P
1-4 outlets
1 PGASRES Residential for ea gas piping system P
of 1-4 Outlets
1 BPGAS For each gas piping system of 5 or P
more per outlet. Comm/Resid
1 BREMAIRHAN Residential A/C units <= I Ok CFM B
p 1 MRRAA Residential Mech Repair/alt/add M
I
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1 BSEISMICR Seismic Residential B
1 EPERMITFEE Electric Permit E
1 MPERMITFEE Mechanical Permit M
1 PPERMITFEE Plumbing Permit P
1 TRAVDOC Travel Documentation B
1 BUSLIC Business License B
M.Indoor Air Quality and Finishes
I-um LMWI*)-VOC Rat 1 IADJHealth pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes p
3•Use towkb VOC A l 3 IAQ/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes D
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 6 IAQ/Health'pts y=yes p
6.Use Exterior Grade Piywood for Interior Uses 1 IAQ/Health pts y=yes D
. _ 1 4 IAQ/Health.pts y=yes p
B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yesI 1 p
1 1 io
N.Flooring
1.Select FSC Certified Wood Flooring B Resource pts y=yes D
2.Use Rapi*Painewable FbDring 10ateaials 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
Total Points Available: I 140 1301 57
Total Points Project Rec L01 0 0
G:datalprogs/greenbui1dino9uidelines/remodelert-Jgreenpointsfinal2-1 Z.04protected.xls
Community Development
{; 10300 Torre Avenue
'a Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�
UPE�TINO
Building Depart ent
JOB ADDRESS: PERMIT #
-Z,1970 2--, - C[RA /0O
OWNER'S NAME: DW 012 l— PHONE # `/09 9 7
GENERAL CONTRACTOR: / „f ; FAX # 70 7 Yq6 70Z&
I am not using any subcontractors: �d
nature Date
Please check applicable subcontractrs anC-Corniffiete the following information:
SUBCONTRACTOR BUSINESS 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
Owner/Contractor Signature Date
CITY OF CUPERTINO
8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32645038 . 00
DATE ISSUED. . . . . . . : 01/04/2010
RECEIPT # . . . . . . . . . : BS000009476
REFERENCE ID # . . . : 10010003
SITE ADDRESS . . . . . : 21890 CORTE MADERA LN
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . :
OWNER . . . . . . . . . . . . : DORIN DEBORAH
ADDRESS 21890 CORTE MADERA LN
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-1129
RECEIVED FROM . . . . : JEFF RAINEY
CONTRACTOR . . . . . . . : GREGORY S. OWEN LIC # 29600
COMPANY . . . . . . . . . . : BLUE MOUNTAIN AIR
ADDRESS . . . . . . . . . . : 707 ALDRIDGE RD STE B
CITY/STATE/ZIP . . . : VACAVILLE, CA 95688
TELEPHONE . . . . . . . . : (707) 451-8111
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- --------
1BCBSC VALUATION 61700 . 00 1. 00 0 . 00 1. 00 0 . 00
1BSEISMICR VALUATION 6, 700 . 00 0 . 70 0 . 00 0 .70 0 .00
lEPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
1MPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
1MRRAA UNITS 2 . 00 126 . 00 0 . 00 126 . 00 0.00
1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0. 00
1PRWHEATR UNITS 1 . 00 25 . 00 0 . 00 25 . 00 0. 00
1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 320 . 70 0 . 00 320 . 70 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 320.70 VISA
---------------
TOTAL RECEIPT 320 .70
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL