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09110059 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10490 MIRA VISTA AVE CONTRACTOR:ASHISH KOTHARI PERMIT NO:09110059 OWNER'S NAME: ASHISH KOTHARI 10490 MIRA VISTA AVE DATE ISSUED: 11/10/2009 ER'S PHONE: 4084552194 CUPERTINO CA,CA 95014-2706 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT r— PLUMB License Class Lic.# MECH r— RESIDENTIAL f— COMMERCIAL Contractor Date I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE THE CURRENT HEATING FURNACE (commencing with Section 7000)of Division 3 of the Business&Professions WITH A NEW ONE 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. Sq.Ft Floor Area: Valuation:$4000 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. APN Number:35704030.00 Occupancy Type: APPLICANT CERTIFICATION I certify that 1 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. 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 Issuedl by: Daty -/��� 9.18. Signature Date RE-ROOFS: hd OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work,and the stricture 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the 1 have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this 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 permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. 1 certify that in the performance of the work for which this permit is issued,l shall not employ any person in any manner so as to become subject to the Worker's Owne or author' a agent: , Date: NOV 9 ^ Compensation laws of California. If,after making this certificate of exemption,I thr � 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. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save inify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional I Signature. Date NOV V �)V n CITY OF CUPERTINO 7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 35704030 . 00 DATE ISSUED. . . . . . . : 11/10/2009 RECEIPT #. . . . . . . . . : BS000009167 REFERENCE ID # . . . : 09110059 SITE ADDRESS . . . . . : 10490 MIRA VISTA AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER ASHISH KOTHARI ADDRESS 10490 MIRA VISTA AVE CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-2706 RECEIVED FROM . . . . : ASHISH KOTHARI CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY ASHISH KOTHARI ADDRESS 10490 MIRA VISTA AVE CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-2706 TELEPHONE . . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 4, 000 . 00 1 . 00 0 . 00 1. 00 0 .00 1BSEISMICR VALUATION 4, 000. 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 1TRAVDOC FLAT RATE 1. 00 42 . 00 0. 00 42 . 00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 232 .50 0 . 00 232 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 232 .50 VISA --------------- TOTAL RECEIPT 232 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL l CDC CITY OF CUPERTINO { FURNACE/AC CUPEkTINO PERMIT APPLICATION FORM APN # L5 + ( � �; Date: NDV 10��1-00 Building Address: 10 �I_oO MTAA Vj-.6/,A A 6u RF1zTTN0, CA c15614- Owner's 5®j4- Owner's Name: i1 5 H i� 1��„H�� 1 Phone#: i5 �g�9.55-21R Contractor: Phone#: 01�NE(�CSELF Fax#: Contractor License#: Cupertino Business License#: Contact: Phone#: Fax #: Building Permit Info: Elect El*" Plumb,n-- Mech r!f-- Residential 1�1 Commercial ❑ Job Description: RF N-AcE 7H E CJ R(?F nJT' HFA 1 I N0, FvPVACr Ah NP W O For Residential Installations: Attic R-, 1St floor F12°d floor ❑ Adhere to minimum setback requirement Ell For Commercial Installations: Replacement same weight ❑ Additional weight(structural calcs) ❑ Structural Calculations required for new installation ❑ New installation Planning Approval Required ❑ Cost of Project: 4000 Type of Construction(Usage Class): Strapped ❑ On Platform ❑ Bonded ❑ New Location ❑ Replacement Project Size: Express 10 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. —� Revised 01/07/09 CITY OF CUPERTINO SJ FURNACEAC CUPEkTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Grou I 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. 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES I BSEISMICR Residential Seismic B I 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> 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 I EPERMITFEE Electric Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M / 1 PPERMITFEE Plumbing Permit P 1 TRAVDOC Travel Documentation B 1 BUSLIC Business License B INPUT Res--u-ns EnLrg� • . n oor Air ua iry an rn►s es 1.Use 1,ow7ND-VOC Paint 1 IAQ/Health pts y=yes 0 2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0 3.Use Low/No VOC Adhesives 3 IAQ/Health pts y=yes p 4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0 5.Use Engineered Sheet Goods with no added Urea Formaldehyde 61AQ/Health pts y=yes p p 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Hsalth pts y=yes y Seal 40Exp osW-PAftAboardor NM 4 IAQ/Health. pts y=yes p 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 1 1 N.Flooring 1.Select FSC Certified Wood Flooring B 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 t t Total Points Available: 1401 1301 57 Total Points Project Received: 0 0 0 Nov Q/ 2009 G:data/progs/greenbuildngguidelines/remodelers/greenpointsfinal212.Mprotected.xls OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate family (parent,spouse or child) will perform: A. All the work authorized by this permit B. _ A portion of the work C. None of the work If B or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hired to do: A. _ All of the work B. _ A portion of the work (complete section below) Contractor Address/City Phone # State License # Type of work to be performed 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City Phone Number Type of work to be performed ..................................................................................................................................................................................... I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner-Builder Information (reverse side). Property Owner's Signature: O,J t, Date: I vD V �� M9 A C..0 P�t) �/ (' Q Permit# �:-_.�� Job Address: -! �STA/� �y�, 0 ' q ©14— Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department.