10010010 CITY OF CUPERTINO BUILDING PERMIT
PERMIT NO:100100 10
CONTRACTOR:CONDITIONED AIR TE IS 01/05/2010
BUILDING ADDRESS: 10221 WESTERN DR DA
1701 LITTLE ORCHARD ST
01VNER'S NAME: LI-QUN XIA SAN JOSE,CA 95125 PHONE NO:(408)291-2220
BIER'S PHONE: 4088738085 PLUMB
• BLDG ELECT
BUILDING PERMIT INFO.
LICENSED CONTRACTOR'S DECLARATION COMMERCIAL
Lic.# . MECH RESIDENTIAL
License Class / V
Date JOB DESCRIPTION:REMOVE&REPLACE FURNACE&ADD A/C
Contractor
er 9
I hereby affirm that I am licensed under the provisions
the Business&tProfessions
(commencing with Section 7000)of Di
Code
3
Code and that my license is in full force and effect.
I hey
reb affirm under penalty of perjury one of the following two de
Compensation,as provided for by Section
I have and will maintain a certificate°f consent to self-insure for Wo 's
ion 3700 of the Labor Code,for the Valuation:$7400
Sq,Ft Floor Area: •
performance of the work for which this pe�ation Insurance,as pit is issued. rovided for by
I have and will maintain Workers Comp Occupancy Type:
Section 3700 of the Labor Code,for the performance of the work for which this APN Number:35911007.00
permit is issued.
APPLICANT CERTIFICATION SIF WOE IS NOT STARTED
certify that I have read this application and state that the e°�,,formation
S ate laws relating PERMIT EXPIRE EOR
I c fY with all city and county ord IT ISSUANCE correct.I agree to comply WITHIN 180 DAYS OF PERM INSPECTION.
o building construction,and hereby authorize representatives
agree to aver CALLED
t roe for inspection pure LAST CA
upon the above mentioned s t City of Cupertino against liabilities,judgments, 180 DAYS FROM
indemnify and keep harm m consequence of the
costs,and expenses which may accrue against saidCity
understands and will c
granting of thiomply Date:�� f c-
s permit. Additionally,the applicant Issued
oint source regulations per the Cupertino Municipal Code,Section
with all non-p
9.18. oo<
Date
Signature RE-ROOFS:
insta
ed.if a roof
All roofs
shall be inspected prior to any roofing material being a all new materialsfor
L
OWNER-BUILDER DECLARATION installed without first obtaining an inspection,I agree to rem
I hereb affirm that I am exempt from the Contractor's License Law for one o inspection. Date:
Y licant:
the following two reasons: Signature of App
baso
caner of the property,or my employees with wages as their sole compensation,
ill do the work,and the structure is not intended or offered for sale(Sec.704
`'�' ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
Business&Professions Code)
I,
as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLoSUR chapter 6.95 of the
affirm under penalty of perjury one of the following three
� I have read the hazardous materials requirements ns 25505,25533,and 25534.under I will maintain
I hereby aff
declarations: Chapter 9.12 and the Health&
ate of Consent to self-insure for Worker's Californi c Healthwith the Cupertino Municipal Code, zardous material.
I have and will maintain a Certificate compliance should I store or handle ha
Com
Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)
p permit is issued. ditionally,should I use equipment or devices which emit hazardous air
Ad Area Air Quality Management District I will
performance of the work for which this pe provided for by contaminants as defined by the Bay p ter 9.12 and the
ensation Insurance,as p Cupertino Municipal Code,Chap
I have and will maintain Worker's Comp maintain compliance with the Cup
Section 3700 of the Labor Code,for the performance of the work for which this Health&Safety Code,Sections 255059 25533,and 25534.
permit is issued.
if that in the per of the work for which this permit is issued,I shat en•
I certify Date:
to an person in any manner so as to become subject to the
exemption,I Own r au
not employ Y
Compensation laws of California. If,after making vhs ons oflthe Labor Code,I must CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensationp
ith comply with such provisions or this permit shall be deemed revoked. that there is a construction lending agency for the performance of work's
forthw P I hereby affirm
APPLICANT CERTIFICATION
for which this permit is issued(Sec.3097,Civ C.)
read this application and state that the above information
relating Lender's Name
I certify that I have r ordinances and state
correct.I agree to comply with all city and county to enter Lender's Address
to building construction,and hereby authorize representatives of this city
for inspection purposes.(We)agree to save
�,��n the above mentionedproperty ments, ARCHITECT'S DECLARATION
lnify and keep harmless the City of Cupertino against liabilities,judgments, public records.
and expenses which may accrue against said City
m consequence of the plans shall be used as p
granting of this permit.Additionally,the applicant understands and will comply I understand my
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Date
Signature C
CITY OF CUPERTINO
PERMIT RECEIPT OPERATOR: patg
1
7 ITEMS OF 7 copy #$
Sec: Twp: Rng: Sub: Blk: Lot:
APN 35911007 .00
DATE ISSUED. . . . . . . 01/05/2010BS000009485
RECEIPT # • • • • " " . 10010010
REFERENCE ID # • • •
SITE ADDRESS . . . . . : 10221 WESTERN DR
SUBDIVISION : : : : : :
CITY • : CUPERTINO
IMPACT AREA . . . . . . •
OWNER . . . . . . . . . . . . : LI-QUN XIA
WESTERN DR
ADDRESS . . . . . . . . . . : 10221 CA 95014-2944
CITY/STATE/
ZIP . . . : CUPERTINO CA, C
RECEIVED FROM CONDITIONED AIR
LIC # 22334
CONTRACTOR . . . . . . . : RICHARD R
COMPANY CONDITIONLE ORCHARD ST
ADDRESS . . . . . . . . . . : 1701 LITD AIR
T CA 95125
CITY/STATE/ZIP SAN JOSE,
TELEPHONE (408) 291-2220
THIS REC NEW BAL
PD-TO-DT ______
y AMOUNT --
FEE ID UNIT QUANTITY __-------- ---------- --------- 0 .00
__ __ ------------- 1 . 00 0 . 00 0 . 00
VALUATION 71400 . 00 0 . 00 0 . 80
1BCBSC 7, 400 .00 0 . 80 42 .00 0 . 00
1BSEISMICR VALUATION 42 .00 0 .00 0 . 00
1 .00 0 .00 42 . 00
1EPERMITFE FLAT RATE 1 .00 42 .00 126 . 00 0 . 00
iMPERMITFE FLAT RA'Z'E .00 126 . 00 0 .00 42 .00 0 . 00
MRRAA UNITS 2 . 00 42 . 00 0 . 00 42 .00 0 . 00
1 1
1PPERMITFE FLAT RATE 1 .00 42 . 00 0 .00 ---------- ----------
1TRAVDOC FLAT RATE ---------- 295 . 80 0 .00
295 . 80 0 . 00
TOTAL PERMIT
AMOUNT REFERENCE NUMBER
METHOD OF PAYMENT --------------- --------------------
____ _ --
----------------- 295 . 80 VISA
CREDIT CARD _______________
295 .80
TOTAL RECEIPT : VOICE ID DESCRIPTION
VOICE
DESCRIPTION -------- -______- ----------------------------
--------------------
-----------------
____------
---------------- _ 507 FINAL PLUMBING
505 FINAL ELECTRICAL
508 FINAL MECHANICAL
CITY OF CUPERTINO
_*. FI:�tNACEAC
CITY OfPERMIT APPLICATION FORM
CUPEkTINO
Date:
APN # �2) 1-- 1 C1 -C)
_i3U_iid_ ing Address:
Wec A—in o ci
0 I�Z-\ Ne Cu Phone#:
Owner's Name: _130 s
Phone#: ct t,
Contractor:
Fax#: - '22Z U
CO C,C Cupertino Business License#:
—Co—ntractor License#:
Phone#:
Contact:
Fax #:
Building Permit Info: plumb
Mech [+�--
Elect
Job Description:
C-,(LA
sue
Resident
i-aJ —C—om—m—er c—ia-1
For Residential Installations: Vt floor El 2nd floor ❑
Attic El
Adhere to minimum setback requirement
For Commercial Installations:
Replacement same weight R
Additional weight(structural calcs)
Structural Calculations required for new installation M
New installation Planning Approval equired [ITClass):
Type of Construction ( ,sage
Cost of Project: 3
Location El
L-A 0 0 0
'New Strapped Er--On Platform Bonded ew Loci'', 1'')1-1 Replacement
Valuation:
Green Building: us attach Green Building Check list to this application
CITY OF CUPERTINO
FURNACEAC
CITY Of
SCHEDULE
LUPE TINOFEE
• Description Fee Permit Type
Quantity Fee ID Fee Des p
Grou
1 MRAPPVNT Residential for the install/relocate/ or M
replacement of ea appliance vent
=FURNACE install ¬ incl in an appl permit.
FURN/AC
1 PGASRES Residential for ea gas piping system of P
1-4 Outlets
piping system of 5 or P
1 BPGAS For each gas
more per outlet.
Cal Bld Standards Commission Fee B ALL PERMIT'
1 BCBSC g TYPES
1BSEISMICR Residential Seismic B
1 MECPLNCK Mechanical Plan Check M
1 MFR=<100 Furnace Syst<=100k BTU install or M
relocate ea forced-air/gravity type
furnace/bumer, 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
type
furnace/burner, incl ducts/vents
attached to such appliance over
100,000 Btu/h
E
1 EPERMITFEE Electric Permit Fee
1MPERM1TFE',-E-j Mechanical Permit Fee M
1PP
ERMITFEE Plumbing Permit P
1
TRAVDOC Travel Documentation PB
1BU
SLIC Business License B
CITY OF CUPERTINO
t
FURNACE/AC
SCHEDULE
CITY OF FEE
CUPEI�TINO
Fee Permit Type
Fee Description Grou
Quantity Fee ID FURN/AC
AIR B
CONDITIONING mercial A/C Units<= IOk CFM
1 BCAIRHAN Com
Commercial Mech Repair/alt/add M CBSC PERMIT
1 MCRAA fission Fee B ALL PE
1 B
Cal Bldg Standards Comm B TYPES
O Seismic Commercial
1BSEISMIC P
Commerical for ea gas piping System
1 PGASCOM 1_4 outlets p
Residential for ea gas piping system
1 PGASRES of 1-4 Outlets p
For each gas piping system of 5 or
sid
1BPGAS more er outlet. Commie B
1 BREMAIRHAN Residential A/C its<= lOk CFM
esidential Mech Repair/alt/add
M
...................
IM R
ee B ALL PERMIT
Bld Standards Commission F TYPES
1BCBSC Cal g
B
1 BSEISMIC
R Seismic Residential
E
ITFEE Electric Permit -
1 SPERM M
'cal Permit
1 MpERM ITFEE Mechanical
1 PPERM
ITFEE Plumbing permit
B
Travel Documentation
IT RAVDOC B
1BUSLIC Business License
M.Indcoar Air Quality and Finishes p .
1 IA(�1Health pts y=yes p
1.l LSV 2 IAQIHealth is es
2.Use Low VOC,Water-Based Wood Finishes P Y=Y p
�1J�e� � 3 IAQJHea]th pts y=yes
4.Use Salvaged Materials for Interior Finishes
3 Resource pts Y--Yes
0
5.Use Engineered Sheet Goods with no added Urea p
Formaldehyde 6 IAQIHealth'pts yy'zs D
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes p
4lAQIHealth pts y=ye
ae1�a��la� F s p
4 Resource is es
8.Use FSC Certified Materials for Interior Finish p y—yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y ). p
10.Install Whole House Vacuum System 31AQIHealth pts y=Yes
e � �
N.FIDoring p
1.Select FSC Certified Wood Flooring B Resource pts y=yes
0
4 Resource pts y=yes
'ae FbDnng lOat�a'iais p
�,Use lapiy �
3.Use Recycled Content Ceramic Tiles 4 Resource pts Mes p
4.Install Natural Linoleum in Place of Vinyl 5 IAQJHealth pts y=yes
4 Resource pts y=YeS 0
5.Use Exposed Concrete as Finished Floor p
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes
Total Points Avalla
ble: 140 130 57
01 0 0
Total Points Project Received:
s:data!progslgreenbuildingguidelineslremodelerslgreenpointstDW2.12.o4protectadxls
Community Development
` 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
CITY OF
'UPE TINO
B • De artment
uoIn
ld
PERMIT #
JOB ADDRESS:
� ;�
C �
PHONE # Z
OWNER S NAME.. FAX# 2 S/ Z.22
GENERAL CONTRACTOR: r`<=�fe- �-�� � � r
ry
/ le
• retractors: ,%y��� '� �- 1
I am not using any subcontractors: Date
Signature
• retractors and com lete the followin information:
Please check applicable subcontractors BUSINESS LICENSE #
SUBCONTRACTOR BUSINESS NAME
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
Date
Owner/Contractor Signature
Community Development
� > 10300 Torre Avenue
,Xa Cupertino CA 95014
a- .
�-
F�^ Telephone(408)777-3228
Fax(408)777-3333
CO.OF
'UPEkTINO
Buildin De art m a nt
JOB ADDRESS: PERMIT #
OWNER'S NAME: r PHONE # �
GENERAL CONTRACTOR* - "We � ` � FAX#
I am not using any subcontractors.
Signature bdt-e
Please check applicable subcontractors and complete the followinginformation:
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