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09110058 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22303 REGNART RD CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO:09110058 DATE ISSUED: 11/10/2009 OWNER'S NAME: RAY&KYLE BANKS • PHONE NO: lER'S PHONE: 4085686916 LICENSED COTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Clas L• # ' MECH I— RESIDENTIAL f COMMERCIAL C ctor Date S JOB DESCRIPTION:REPLACE SPLIT SYSTEM HEAT PUMP,GEO I hereby affirm that I am licensed under the provisions of Chapter 9 THERMAL (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. Sq.Ft Floor Area: Valuation:$18900 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 APN Number:36602043.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We)agree to save 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. Additiona ly,the applicant understands and will comply with all non-pont sou a regulat' ns er the Cupertino Municipal Code,Section Issued by: 9.18. S ature Date RE-ROOFS: L, 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: Date: I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE I hereby affirm under penalty of perjury one of the following three declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I 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. Additionally,should I use equipment or devices which emit hazardous air 1 have and will maintain Worker's Compensation Insurance,as provided for by contaminants as defined V the Bay Area Air Quality Management District I will Section 3700 of the Gabor Code,for the performance of the work for which this maintai compliance wi the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health Safety ode, ections 25505,25533,and 25534. 1 certify that in the performance of the work for which this permit is issued,I shall I I not employ any person in any manner so as to become subject to the Worker's Owner a ettj Date: Y Compensation laws of California. If,after making this certificate of exemption,I l 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.1 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 -mify 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 Licensed Professional 9.18. Signature Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 36602043 .00 DATE ISSUED. . . . . . . : 11/10/2009 RECEIPT #. . . . . . . . . BS000009164 REFERENCE ID # 09110058 SITE ADDRESS 22303 REGNART RD SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER RAY & KYLE BANKS ADDRESS . 22303 REGNART RD CITY/STATE/ZIP CUPERTINO, CA 95014 RECEIVED FROM TBD -SOLUTIONS,OEBE LIC # 00096 CONTRACTOR . . . . . . . COMPANY TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP , TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC --NEW-BAL- ---------- ------------- ---------- ---------- ----- 1BCBSC VALUATION 18, 900 . 00 1 .00 0 .00 1. 00 0 .0 1BSEISMICR VALUATION 18, 900 . 00 1.90 0 .00 1. 90 0 .00 lEPERMITFE 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 1. 00 63 . 00 0 .00 63 . 00 0 .00 1MRRAA UNITS 1PPERMITFE FLAT RATE 1. 00 42 . 00 0 .00 42 . 00 0_00 ---------- ---------- ---------- ------ TOTAL PERMIT : 191 . 90 0 .00 191 . 90 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- -- --------------- ---- CHECK 191 . 90 #14167 --------------- TOTAL RECEIPT 191 . 90 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -- _ ------ --------- ------------------ -- ----------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL 0 11/ CITY OF CUPERTINO k FURNACE/AC CUPS TING PERMIT APPLICATION FORM APN # ,--3 b � o ;' v ` J Date:` Building Address:Ow 5S Phone Contractor: 1 Phone#: Gl 16,-S�Z.Z444- .INC` '2 �L��d i,S `1-�C ��- (l `� Fax#: CW, - Contractor License#: (I -I J 1 Cupertino Business License#: -1 'l Phone# � gO� Contact: � -O n z'7 I T-% * S Fax # k — S� Building Permit Info: Elect E�-- Plumb Mech -�' Residential � Commercial E] Job Description: For Residential Installations: 2°d floor [:1Attic 1-115t floor Adhere to minimum setback requirement ❑ For Commercial Installations: Additional weight(structural calcs) ❑ Replacement same weight ❑ Structural Calculations required for new installation ❑ New installation Planning Approval Required ❑ Cost of Project: Type of Construction (Usage Class): liet 0 Strapped ❑ On Platform ❑ Bonded New Location❑ Replacement Project Size: Express 0�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 2 FURNACE/AC CM OF FEE SCHEDULE CUPEkTINO Quantity Fee ID Fee Description Fee Permit Type Grou 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 1BPGAS 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 C I � � 1MECPLNCK 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 1 EPERMITFEE Electric Permit Fee E 1MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Permit P I 1TRAVDOC Travel Documentation B 1BUSLIC Business License 13 Community Development `ry. 10300 Torre Avenue Cupertino CA 95014 Yc Telephone(408)777-3228 �C1TY OF Fax(408)777-3333 „UPEkTINO BuildinDe artment JOB ADDRESS: PERMIT # OWNER'S NAME: fir. PHONE GENERAL CONTRACTOR: Q, I am not using any subcontr tors: Ok,XU Signature ate Please check applicable subcontractors and complete the followin 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 owner/Contractor Signature Date