10010060 CITY OFCUPERTINO BUILDING PERMIT PERMIT NO:10010 060
CONTRACTOR:CONDITIONED AIR TE ISSUED:01/13/2010
BUILDING ADDRESS: 10541 DAMSON AVE DA 1701 LITTLE ORCHARD ST
PHONE NO:(408)291-2220
OWNER'S NAME: ANUJ KHANDELWAL SAN JOSE,CA 95125
1ER'S PHONE: 6508883316 � T� PLUMB
BUILDING PERMIT INFO: BLDG ELECT
LICENSED CONTRACTOR'S DECLARATION F COMMERCIAL
� �3 3 MECH RESIDENTIAL
License Class
Lic.# 1 9 Q
SJDc a :3 �I V
L N
JOB DESCRIPTION:REMOVE&REPLACE FURNACE&A/
Contractor
the rovisions of Chapter 9
I hereby affirm that I am license undo ion 3 of the Business&Professions
(commencing with Section 7000)of D
ivisCode and that my license is in full force and effect.
I hereby
affirm under penalty of perjury one of the followifog two
f consent to self-insure
Compensation,as provided for by Sect rations:
I have and will maintain a certificate°ion 3700 of the Labor Code,for the Valuation:$7150
Sq.Ft Floor Area:
performance of the work for which this permit
Insurance,ce,as provided for by
I have and will maintain Workers CompensationOccupancy Type:
Code,for the performance of the work for which this APN Number:36913058.00
Section 3700 of the Labor
permit is issued.
APPLICANT CERTIFICATION RES IF WOE IS NOT STARTED
that I have read this application and state that the above information� laws relating PERMIT EXPIRES NCE OR
1 certify IT ISSUANCE 1 with all city and county ordinances
correct.I agree to comply WITHIN 180 DAYS OF PE
building construction,and hereby authorize represenoases- (We)agree to aver CALLED INSPECTION.
to but g for inspection pure LAST
upon the above mentioned property 180 DAYS FROM
of Cupertino against liabilities,judgments,
indemnify and keep harmless the City In consequence of the
against said City Dater
costs,and expenses which may accrue ag licant understands and will comply ,_.�---
granting of this permit. Additionally,the app Issued b�.-
rce re ulations per the Cupertino Municipal Code,Section
with all non-point sou g
9.18. /v
Date
Signature RE-ROOFS:
11 be inspected prior roofing material being installed.If a roof is
All roofs shall drior to an
an Inspection,I agree to remove all new materials for
OWNER-BUILDER DECLARATION installed without first obtaining
u inspection. �
I hereby affirm that I am exempt from the Contractor's License Law for one of Date:
the following two reasons:or my employees with wages as their sole compensation,
Signature of Applic t:
1,as owner of the property,
work,and the structure is not intended or offered for sale(Sec.7044, COVERINGS TO BE CLASS"A"OR BETTER
will do theALL ROOF
Business&Professions Code) acting with licensed contractors to
I,as owner of the property,am exclusively contr
HAZARDOUS MATERIALS DISCLOSURE 6.95 of the
construct the project(Sec.7044,Business&Professions Code). under Chapter
under malty of perjury one of the following three I have read the hazardous materials requirements and P
hereby affirm u p &Safety Code,Sections 25505,25533,and 2553 the Health&aIn
I y
534. 1 will maint
declarations: Chapter 9.1
compliance with the Cupertino Municipal o ehandle hazardous material.
in a Certificate of Consent to self-insure for Worker's California Heat I
I have and will mamta Safety should
Compensation,as provided for by Section 3700 of the Labor Code,for the Code,Section 25532(5)
Com ed. all should I use equipment or devices which Quality
Ma agement District I will
p Additionally,
performance of the work for which this permit Is Issu rovided for by the Bay Area Air alter 9.12 and the
as contaminants as defined by Chap
I have and will maintain Worker's Compensation Irathe,work for which this maintain compliance with the Cupertino Munici al Code,
of Health&S ode Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance
permit is issued.
' rmance of the work for which this permit is issued,I o ` r'�
In the Perfo
I certify that come subject to the Worker's Owne Date:
not employ any person in any manner so as to be
ion laws of California. If,after making this certificate CodeoI must DING AGENCY
compensation Compensation provisions of the Labor
ex
CONSTRUCTION LE performance of work's
become subject to the Worker's Comp agency for the p
' comply with such provisions or this permit shall be.deemed revoked. affirm that there is a construction lending g y
forthwith P y I hereby a
for which this permit is issued(Sec.3097,civ C.)
APPLICANT CERTIFICATION Lender's Name
that I have read this application and state that the above information e
I certify 1 with all city and county ordinances and state laws relating
correct.I agree to comp y to enter Lender's Address
building construction,and hereby authorize representatives of this city
to b g for inspection purposes.(We)agree to save
on the above mentioned property a ainst liabilities,judgments, ARCHITECT'S DECLARATION
u y ertmo g
p ,tnnify and keep harmless the Cit of Cup In consequence of the plans shall be used as public records.
and expenses which may accrue against said City I understand my
of this ermit.Additionally,the applicant understands and will comply
granting P per the Cupertino Municipal Code,Section
Professional-------------------
with all non-point source regulations p Licensed Professional
9.18. 10
Date
Signature
j.
CITY OF CUPERTINO BUILDING PERMI
CONTRACTOR:CONDITIONED AIR
PERMIT NO:10010060
BUILDING ADDRESS: 10541 DAMSON AVE DATE ISSUED:01/13/2010
1701 LITTLE ORCHARD ST
OWNER'S NAME: ANUJ KHANDELWAL PHONE NO:(408)291-2220
. SAN JOSE,CA 95125
NER'S PHONE: 6508883316 .
O: BLDG ELECT PLUMB
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INF F
C' c.#. � �6Z' MECH I— RESIDENTIAL COMMERCIAL
License Class
Contractor
Date JOB DESCRIPTION:REMOVE&REPLACE FURNACE&A/C
I hereby affirm that I am licensed under the n 3 o the Business&te Professions
(commencing with lscensen s on full force00)of and effect.
Code and Y
I hereby affirm under penalty of perjury
one of the following two declarations:
I have and will maintain a certificate of consent to self-Labor Code,for the
nsure for Worker's Mw�
Compensation,as provided for by Section 3700 of the Valuation:$7150
Sq.Ft Floor Area:
performance of the work for which this permit is issued. provided for by
I have and will maintain Workers Compensation Insurance,asp Occupancy Type:
Section 3700 of the Labor Code,for the performance of the work for which this APN Number:36913058.00
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the ces and state laws relating IT EXPIRES IF WOE IS NOT STARTED
ation is
with all city and county ordinances PERM
correct.I agree to comply ty WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter WI•r INSPECTION.
for inspection purposes. (We)agree to save
upon the above mentioned property p 180 DAYS FROM LAST CALLED
indemnify and keep harmless the City of Cupertindo against City in consequence of the judgments,
costs,and expenses which may accrue agaihe ansl cant understands and will comply /�~ Date:
ranting of this permit. Additionally,t pp o Municipal al Code,Section Issued b��
g er the Cu erten p
with all non-point source regula' p
9.18.
Date
Signature RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
OW
NER-BUILDER DECLARATION 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. Date:
the following two reasons: Signature of Applicant:
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044, VERT NGS TO BE CLASS"A"OR BETTER
Business&Professions Code) ALL ROOF CO
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE
hereby affirm under penalty of perjury one of the following three I have read the hazardous materials requirements undor Chapter and 25534.91 of the
maintai
I Y
declarations: ate of Consent to self-insure for Worker's California Health&Safety Code,Sections 2550 Chapter 9.12 and the Health&
I have and will maintain a Certific compliance with the Cupertino Municipal Code,
Safety Code,Section 25532(a)should I store or handle hazardous material.
Compensation,as provided for by Section 3700 of the Labor Code,for the P
he work for which this permit is issued. Additionally,should I use equipment or devices lw h is Man gement District I will
it hazardous air
performance oft provided for by
which this contaminants as defined by the Bay Area Air Q Chapter 9.12 and the
I have and will maintain Workers Compensation Insurance,as P maintain compliance with the Cupertino Municipal Code,
Section 3700 of the Labor Code,for the performance of the work for wh Health&Safety Code,Sections 25505,25533,and 25534.
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall
a 111;JZ1 not employ any person in any manner so as to become subject to the Worker's Owner or aut ion,I Date.
Compensation laws of California. If,after making this certificate of ex C de,I must
P
become subject to the Worker's Compensation provisions
shall f the Lab revoked. CONSTRUCTION LENDING AGENCY
forthwith comply with such provisions or this permit
I hereby affirm that there is a construction lending agency for the performance of wort
TIFICATION for which this permit is issued(Sec.3097,Civ C.)
APPLICANT CER
certify that I have read this application and state that the above d information
o a laws relating Lender's Name
I ce fy with all city and county ordinances an
correct.I agree to complycity
in construction,and hereby authorize representatives of this agree to to
eer Lender's Address
to building for inspection purposes.(We)
upon the above mentioned property P
a e harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATIO
emn�fy and ke p
and expenses which may accrue against said understands and will comply I understand my plans shall be used as public records.
b:anting of this permit.Additionally,the applicant
with all non-point source regula' ns Vr the Cupertino Municipal Code,Section Licensed Professional
9.18. �Q
Date
Signature
CITY OF CUPERTINO
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 36913058 . 00
DATE ISSUED. . . . . . . : 01/13/2010
RECEIPT # . . . . . . . . . : BS000009554
REFERENCE ID # . . . : 10010060
SITE ADDRESS . . . . . : 10541 DAVISON AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : ANUJ KHANDELWAL
ADDRESS . . . . . . . . . . : 10541 DAVISON AVE
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4503
RECEIVED FROM . . . . : CONDITIONED AIR
CONTRACTOR . . . . . . . : RICHARD READ LIC # 22334
COMPANY . . . . . . . . . . : CONDITIONED AIR
ADDRESS . . . . . . . . . . : 1701 LITTLE ORCHARD ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408) 291-2220
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- -------------
---------- -----
1BCBSC VALUATION 71150 . 00 1 . 00 0 . 00 1 . 00 0. 00
1BSEISMICR VALUATION 71150 . 00 0 . 80 0 . 00 0 . 80 0. 00
1EPERMITFE 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
1TRAVDOC FLAT RATE 1.00 42 . 00 0 . 00 42 . 00 0. 00
---------- ---------- ---------- ---
TOTAL PERMIT 295 . 80 0 . 00 295 . 80 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 295 . 80 VISA
---------------
TOTAL RECEIPT 295 . 80
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
CITY OF C UPERTINO
FURNACE/AC
CTINO
CUPEITY PERMIT APPLICATION FORM
APN # Date:
9I o f 31 � ►
Building Address:
U e
0, �,�D Y-) -f--) 01 SOCA
CA
Owner's Name: Phone#:
Contractor: Phone#:
Fax #: t4 05 0
I I
Contractor License#: Cupertino Business License#:
,-ALA k
Contact: Phone#:
v1 Leo e -,r-0n,A
Fax #:
Building Permit Info:
Elect Plumb Mech E11--
Job Description:
(i�f n-:Z) Ce ctqN J% 4'1 Cr
Residential Lo Commercial
For Residential Installations:
Attic ❑ I` floor ❑ 2nd floor F-1
Adhere to minimum setback requirement
For Commercial Installations:
Replacement same weight Ej- Additional weight (structural calcs) ❑
Structural Calculations required for new installation F-1
New installation Planning Lkaroval Required ❑
Cost of Project: Type of Construction (Usage Class):
,\"/5
sljQ
C, C.,
Strapped El On PlatfbrmET---'-' Bonded 0 New Location EJ-' Replacement
Valuation:
0 oG
Green Building: Must attach Green Building Check list to this application
CITY OF CUPERTIN0
FURNACEAC
CITY OF SCHEDULE
_UPETINSFEE
• Fee Description Fee Permit Type
Quantity Fee ID 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
1BPGAS 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 ¬ incl in an appliance
permit. . ion Fee B ALL PERMIT
E:::tl BCBSC Cal Bldg Standards Commiss ES
TYP
1BSEISMIC0 Commercial Seismic B
1M
RRAA Residential 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.
M
1 MRSUSHTR Residential Install/Relocate ea
suspended heater,recessed wall htr, or
floor mounted unit heater.
CITY OF CUPERTINO
{
FURNACEAC
CITY OF SCHEDULE
CUPE TINO FEE
�,
• Fee Description Fee Permit Type
Quantity Fee ID Grou
1 MRAPPVNT Residential for the install/relocate/ or M
replacement of ea appliance vent
install ¬ incl in an appl permit.
FURN/AC
FURNACE
1 PGASRES Residential for ea gas piping system of P
1-4 Outlets
1BPGAS For each gas piping system of 5 or P
more per outlet.
Cal Bldg Standards Commission Fee B ALL PERMIT
1 BCBSC g TYPES
1BSEISMICR Residential Seismic
B
r
1 MECPLNCK Mechanical Plan Check M
1 MFR=<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> 100k 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
I P
1 PPERMITFEE Plumbing Permit
C
1
TRAVDOC =Travel Documentation B
B
1 BUSLIC Busi
ness License
Community Development
- 10300 Torre Avenue
s , Cupertino CA 95014
Telephone(408)777-3228
;FY^
Fax(408)777-3333
CITY OF
1UPEkTINO
Building Depart ent
JOB ADDRESS: PERMIT #
. L
ADDRESS: ('110
/6-� ql
Dav� /4 ve
OWNER'S NAME: G Ct k-c P�=�
PHONE # O r
GENERAL CONTRACT R: �4 6Me FAX#
r
I am not using any subcontractors:
Signature ate
Please check a licable subcontractors and complete 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