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09110152I CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 21334 DEXTER DR I CONTRACTOR: SANDIUM I PERMIT NO: 09110152 OWNER'S NAME: MITZY & ERIC BUTTE 4223 VERDIGRIS CIR DATE ISSUED: 11/30/2009 IER'S PHONE: 4088949072 1 SAN JOSE, CA 95134 1 PHONE NO: (408) 894-9072 LICENSED CONTRACTOR'S`` DECLARATION License Class Lic. # 4� Contractor Date I hereby affirm that I 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 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 1 certify that I have read this application and state that the above information is correct. 1 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 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 "��,+/I�/ , IG Date � ` �� LI OWNER -BUILDER DECLARATION 1 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) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I 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. 1 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. 1 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 upon the above mentioned property for inspection purposes. (We) agree to save unify and keep harmless the City of Cupertino against liabilities, judgments, .., 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 BUILDING PERMIT INFO: BLDG i ELECT r— PLUMB f— MECH F RESIDENTIAL f- COMMERCIAL F JOB DESCRIPTION: FURNACE REPLACEMENT Sq. Ft Floor Area: I Valuation: $3800 APN Number: 32641073.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by ) ,==— 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. I 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 compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. O er or thoy _ rized i q `�.—i Date: CONSTRUCTION LENDING AGENCY 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.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32641073.00 DATE ISSUED.......: 11/30/2009 RECEIPT #.........: BS000009291 REFERENCE ID # ...: 09110152 SITE ADDRESS .....: 21334 DEXTER DR SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OPERATOR: patg COPY # : 1 OWNER ............: MITZY & ERIC BUTTE ADDRESS ..........: 21334 DEXTER DR CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-1317 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 ---------- 3,800.00 ---------- 1.00 ---------- 0.00 ---------- 1.00 0.00 1BSEISMICR VALUATION 3,800.00 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 ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 190.50 --------------- 190.50 VOICE ID DESCRIPTION -------- ---------------------------- 505 FINAL ELECTRICAL 508 FINAL MECHANICAL REFERENCE NUMBER -------------------- VISA VOICE ID DESCRIPTION -------- ---------------------------- 507 FINAL PLUMBING I I I c>l �2- CITY OF CUPERTINO FURNACE/AC CUPEkTINO PERMIT APPLICATION FORM APN #� �� 41 -2-) - ,: _ � Date: n , 1 Building Address: Owner's Name: �- Phone #: 974- cit; l L Contractor: Phone #: j Fax #: Contractor License #: Cupertino Business License #: Contact: � � Phone #: � 00 c2,?j' Fax #: Building Permit Info: Elect -of Plumb Mech Residential Commercial ❑ Job Description: For Residential Installations: Attic ❑ I` floor 2r 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: Type of Construction (Usage Class): Strapped ❑ On Platform Bonded New Location ❑ Replacement E;/ Project Size: xpress ES --"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. xevisea uiiuiiuy CITY OF CUPERTINO FURNACE/AC COF CUPERTINO 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. IBCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR 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 1MFRN>100 Furnace Syst > I 00 BTU install or M relocate ea forced-air/gravity type furnace/burner, incl ducts/vents attached to such appliance over 100,000 Btu/h j 1 EPERMITFEE Electric Permit Fee E / 1 1 MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE Plumbing Permit P 1 TRAVDOC Travel Documentation B 1 BUSLIC Business License B 1. Use LowNo-V®C Paint 1 IAWealth pts y=yes 2. Use Low VOC, Water -Based Wood Finishes 2 IAD/Health pts y=yes 3. Use LDw/Nlo 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 4 Resource 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 11 tioleboard or MDF 4 IAQJHealth pts y=yes B. 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 lACWHealth pts y=yes N. Fiooring 1. Select FSC Certified Wood Flooring B Resource pts y=yes 2. Use Rapidly Banewahle 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 Unyl . 5 IATH8kh 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: 1401 130E---5'-71 0 0 Q t� G:data/progslgreenbuilcfingguidefines/remode erslgreenpoin na1212D4proteoted.zls r 1 CITY OF -..;UPEkTIN0 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: J 21 4-� `f� PERMIT # i (� ► 2- OWNER'S NAME: e- PHONE # 1 qa 12 GENERAL CONTRACTOR: ; �,�„ FAX # I am not using any subcontractors: :::�� -=L \ h,�/"q Signature Date Please check applicable subcontractors and complete the following information: Owner/ Contractor Signature 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 Owner/ Contractor Signature Date