09090180 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20891 MC CLELLAN RD CONTRACTOR:SANDIUM PERMIT NO:09090180
OWNER'S NAME: ESTHER WONG 4223 VERDIGRIS CIR DATE ISSUED:09/24/2009
ER'S PHONE: 4084972337 SAN JOSE,CA 95134 PHONE NO:(408)894-9072
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F ELECT F PLUMB F
License Class CZo _ Lic. `l `# q,
(( L� MECH f— RESIDENTIAL f— COMMERCIAL�
Contractor SA"'11A-,% Date `�2�'>�
JOB DESCRIPTION:FURNACE RELOCATION TO ATTIC AND AC ADD
I hereby affirm that 1 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 Sq.Ft Floor Area: Valuation:$12000
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 APN Number:35913083.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
1 certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Z
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section /
9.18. q
Signature w `� •�' Date l � L
RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
[� OWNER-BUILDER DECLARATION installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: Signature of Applicant: Date:
1,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,
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE
1 hereby affirm under penalty of perjury one of the following three I have read the hazardous materials requirements under Chapter 6.95 of the
declarations: California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain a Certificate of Consent to self-insure for Worker's compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should I store or handle hazardous material.
performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I have and will maintain Worker's Compensation Insurance,as provided for by 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
Section 3700 of the Labor Code,for the performance of the work for which this 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 Owne uthorized geW �y
not employ any person in any manner so as to become subject to the Worker's � h•n"• Date:
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 CONSTRUCTION LENDING AGENCY
forthwith comply with such provisions or this permit shall be deemed revoked. I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued(Sec.3097,Civ C.)
APPLICANT CERTIFICATION Lender's Name
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 Lender's Address
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
it nify and keep harmless the City of Cupertino against liabilities,judgments,
C. and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35913083 . 00
DATE ISSUED. . . . . . . : 09/24/2009
RECEIPT #. . . . . . . . . BS000008754
REFERENCE ID # . . . : 09090180
SITE ADDRESS . . . . . : 20891 MC CLELLAN RD
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER ESTHER WONG
ADDRESS 20891 MC CLELLAN
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2957
RECEIVED FROM . . . . : YIU-HANG LEE
CONTRACTOR MICHAEL LEE LIC # 28867
COMPANY SANDIUM
ADDRESS 4223 VERDIGRIS CIR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95134
TELEPHONE (408) 894-9072
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 12, 000 . 00 1 . 00 0 . 00 1. 00 0 .00
1BSEISMICR VALUATION 12, 000 . 00 1 .20 0 . 00 1 .20 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 296 .20 0.00 296 .20 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 296 .20 VISA
---------------
TOTAL RECEIPT 296 .20
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
C) C)
.. CITY OF CUPERTINO
FURNACE/AC
OF
CUPEkTINO PERMIT APPLICATION FORM
APN # � ��d • � � Date:
Building Address:
Owner's Name: Phone#:
L-o 77 2337
Contractor: Phone#: ( C�,o? Z
'Sa", ```" Fax#:
Contractor License#: Cupertino Business License#:
Contact: �n /� � _ Phone#:49 6% 0ZV
1 Fax #:
Building Permit Info:
Elect ErPlumb Q'" Mech
Residential,,❑ Commercial ❑
Job Description: - F,4 rmt-c, � `G AC
agj—
For Residential Installations:
1St floor El2°d floor
Attic Er ❑
Adhere to minimum setback requirement
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):
-4l2.ee�a L-�
Strapped ❑ On Platform ET Bonded New Location ❑ Replacement
Project Size: Express 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 plan set & the sheet index.
Z.
Revised 01/07/09
Y. CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO 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.
1MCSUSHTR Commercial Install/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted unit heater.
1PGASCOM Commerical for ea gas piping System P
1-4 outlets
1 BPGAS For each gas piping system of 5 or P
more per outlet.
1MCAPPVNT Commercial for the install/relocate/ or M
replacement of ea appliance vent
installed & not incl in an appliance
permit.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Commercial Seismic B
1 MRRAA 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.
1MRSUSHTR Residential Install/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted unit heater.
CITY OF CUPERTINO
az - FURNACEAC
CUPEkTINO 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
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICO 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
IBPGAS For each gas piping system of 5 or P
more per outlet. Comm/Resid
1 BREMAIRHAN Residential A/C units<= I Ok CFM B
1 MRRAA Residential Mech Repair/alt/add M
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
I 1 EPERMITFEE Electric Permit E
1MPER.MITFEE Mechanical Permit M
1 PPERMITFEE Plumbing Permit P
1 TRAVDOC Travel Documentation B
1BUSLIC Business License B
INPUT Resources Energy IAQ/Health
Indoor Air Quality and Finishes
1.Use Low/ND-VOC Paint 1 IAQ/Health pts y=yes 0
2.Use Low VOID,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3.Use Low/No VOC Adhesives 3 IAQ/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 6IAQ/Health pts y=yes D
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7.Seal all'Exposad fftftleboard or MDF 4 IAQ/Health pts y=yes 0
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=yes 0
1 i 1
N.Flooring
1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0
.2.Use Rapidly Renewable Flooring Materials 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
1 1 1
Total Points Available: 1 1401 1301 57
Total Points Project Received: C�1 01 01 0
7,/
G:data/progs/greenbuildngguidelines/remodelers/greenpointsfinal2.12.D4protected.xls
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�MkTINO
Building Department
JOB ADDRESS: PERMIT #
OWNER'S NAME: PHONE # 4a 4- o 72
GENERAL CONTRACTOR: FAX#
I am not using any subcontractors:
Signature Date
Please check applicable 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
zs,_� 7-w -q
Owner/Contractor Signature Date