09110121CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21762 COLUMBUS AVE CONTRACTOR: AAA FURNACE & AIR PERMIT NO: 09110121
CONDITIONING
OWNER'S NAME: JENNIFER LENG
JER'S PHONE: 4087250497
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Q—qJ / C Zc: Li,. # % 6 9 '�- -7/
Contractor o f 7,' e Date
I hereby affirm that I am licensed under 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.
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
permit is issued.
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
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may clue against said City in consequence of the
granting of this permit. Addi 'onilly, the applicant understands and will comply
with all non -point sour ations per the Cupertino Municipal Code, Section
9.18.
Signature Date
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
1 hereby affirm under penalty of perjury one of the following three
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
permit is issued.
I 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
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
forthwith comply with such provisions or this permit shall be deemed revoked.
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
to building construction, and hereby authorize representatives of this city to enter
+ --i the above mentioned property for inspection purposes. (We) agree to save
mify and keep harmless the City of Cupertino against liabilities, judgments,
CWLS, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature
Date
1712 STONE AVE
SAN JOSE, CA 95125
DATE ISSUED: 11/20/2009
PHONE NO: (408)2934717
BUILDING PERMIT INFO: BLDG f— ELECT F PLUMB f—
MECH f— RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: REMOVING EXISTING FURNACE INSNTALL NEW
FURNACE
SAME LOCATION
Sq. Ft Floor Area: I Valuation: $4750
APN Number: 35618041.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued b Date. -
RE -ROOFS:
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
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District 1 will
maintain compliarif a with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safede, Sections 25505, 25533, and 25534.
agent:
Date: ,
1 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.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
6 ITEMS OF 12
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 35618041.00
DATE ISSUED.......: 11/20/2009
RECEIPT #.........: BS000009248
REFERENCE ID # ...: 09110121
SITE ADDRESS .....: 21762 COLUMBUS AVE
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......
OWNER JENNIFER LENG
ADDRESS 21762 COLUMBUS AVE
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
OPERATOR: patg
COPY # : 1
RECEIVED FROM ....: AAA FURNACE &AIR CO
CONTRACTOR .......: RANDO, JIM LIC # 8050
COMPANY AAA FURNACE & AIR CONDITIONING
ADDRESS 1712 STONE AVE
CITY/STATE/ZIP ...: SAN JOSE, CA 95125
TELEPHONE (408)293-4717
FEE ID
UNIT
QUANTITY
AMOUNT
PD -TO -DT
THIS REC
----------
NEW BAL
----------
----------
1BCBSC
-------------
VALUATION
----------
4,750.00
----------
1.00
----------
0.00
1.00
0.00
1BSEISMICR
VALUATION
4,750.00
0.50
0.00
0.50
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
1.00
63.00
0.00
63.00
0.00
1PPERMITFE
FLAT RATE
1.00
42.00
0.00
42.00
0.00
----------
TOTAL PERMIT
----------
190.50
----------
0.00
----------
190.50
0.00
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT
AMOUNT
---------------
381.00
---------------
381.00
VOICE ID DESCRIPTION
-------- ----------------------------
505 FINAL ELECTRICAL
508 FINAL MECHANICAL
REFERENCE NUMBER
--------------------
#35075
VOICE ID DESCRIPTION
-------- ----------------------------
507 FINAL PLUMBING
.f.
CITY OF
CUPEkTINO
CITY OF CUPERTINO
FURNACE/AC
PERMIT APPLICATION FORM
0911 0/.2 1
APN #
5 Ctl �'C) v v
Date:
1 I— y --d9
Building Address:
Owner's Name:
Phone #:
Jenn; er- len
40S-las-ati�
Contractor: -RQ o '.J 6 1-1 v ,a C R flA FN rrXce ('
Phone #: tip& —9-c13
Fax #: 4 DS -619 -
Contractor License #: --7 to f�- 9 7 /
Cupertino Business License #:
Contact: C -7o r l % i,4-) Z t'(L
Phone #: �-o �7- - 7 r} 5 - o,y 9 7
Fax #:
Building Permit Info:
Elect C4' Plumb Mech [►�-
Residential [�J' Commercial ❑
Job Description: Z e rn c v ; n Jc &4� i 5+ 1 n3 FL irs-joC -e 110,57W11 N e,�-O PLIC. -4 Ce
.Same loco+ -v, -i
For Residential Installations:
Attic ❑ 1St floor ID,2°d floor ❑
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: 4 -7 -So, v0 Type of Construct' (Usage Class):
Strapped On Platform ❑ Bonded New Location Replacement El -
-Project
Project Size: Express ❑ Standard ❑ Large ❑ Major ❑
Valuation: 14 7 5-0 - o o
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.
xevisea uiiuii09
CITY OF CUPERTINO
51-FURNACE/AC
CUPEI�TINO FEE SCHEDULE
Quantity
Fee ID
Fee Description
Fee
Permit Type
Group
1MRAPPVNT
Residential for the install/relocate/ or
M
replacement of ea appliance vent
install & not incl in an appl permit.
FURNACE
FURN/AC
1PGASRES
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.
1BCBSC
Cal Bldg Standards Commission Fee
B
ALL PERMIT
TYPES
1BSEISMICR
Residential Seismic
B
I tyA WNN
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/bumer, incl ducts/vents
attached to such appliance over
100,000 Btu/h
I
1 EPERMITFEE
Electric Permit Fee
E
1MPERMITFEE
Mechanical Permit Fee
M
1
1 PPERMITFEE
Plumbing Permit
P
1 TRAVDOC
Travel Documentation
B
1BUSLIC
Business License
B
1. Use'Lo►1No-VOG Feint
1 IAQ/Health pts
y=yes
2. Use Low VOC, Water -Based Wood Finishes
2 IAQ/Health pts
y=yes
3. Use Lowft VOC Adhesives
3 IAQ/Health pts
y=yes
4. Use Salvaged Materials for Interior Finishes
3 Resource pts
y=yes
5. Use Engineered Sheet Goods with no added Urea
5 IAQ/Health pts
y=yes
Formaldehyde
61AQ/Health pts
y=yes
6. Use Exterior Grade Plywood for Interior Uses
1 IAQ/Health pts
y=yes
7. Seal al &posed Particleboard or MIDF
4 IAQ/Health. pts
y=yes
8. Use FSC Certified Materials for Interior Finish
4 Resource pts
y=yes
9. Use Finger -Jointed or Recycled -Content Trim
1 Resource pts
y=yes
10. Install Whole House Vacuum System
3 IAQ/Health pts
y=yes
N. Flooring
1. Select FSC Certified Wood Flooring
8 Resource pts
y=yes
2. Use Rapidly Renewable Flooring Materials
4 Resource pts
y=yes
3. Use Recycled Content Ceramic Tiles
4 Resource pts
y=yes
4. Install Natural Linoleum in Place of Vinyl
5 IAQ/Health pts
y=yes
5. Use Exposed Concrete as Finished Floor
4 Resource pts
y=yes
6. Install Recycled Content Carpet with Low VOCs
4 Resource pts
y=yes
Total Points Available:
Total Points Project Received:
I
—1401 130 57
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.•fir
CITY OF
XPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS: a 1--7 l02 �► a l u w•
PERMIT #
6��
OWNER'S NAME: P n ; - r 1 -er
PHONE # ps- - 7a, S - C7 4
GENERAL CONTRACTOR: 9 VA C-
FAX # 4o8 -(:9L5 3 - & -2 -7
I am not using any subcontractors:
Signature
Please check applicable subcontractors and complete the following information:
Date
a
Owner/Contractor ature
- S'6 <7'
Date
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
a
Owner/Contractor ature
- S'6 <7'
Date