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09100105 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10285 DEMPSTER AVE CONTRACTOR:SANDIUM PERMIT NO:09100105 OWNER'S NAME: PATRICK CHAN 4223 VERDIGRIS CIR DATE ISSUED: 10/19/2009 ER'S PHONE: 4088949072 SAN JOSE,CA 95134 PHONE NO:(408)894-9072 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class C-ZO Li..# MECH f— RESIDENTIAL f— COMMERCIAL r Contractor <-''�"�-�"�.. Date 0A �Q 61 I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:FURNACE REPLACEMENT&AC ADDITION (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:$1100 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:32647083.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree 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 _ granting of this permit. Additionally,the applicant understands and will comply IssuedXy: DateX�,) with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Signature Date RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is Ei 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: I,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) 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 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 Own o authorized agent: � y not employ any person in any manner so as to become subject to the Worker's Date:1�f,- �F Q?10 ` Compensation laws of California. If,after making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,1 must CONSTRUCTION LENDING AGENCY forthwith comply with such provisions or this permit shall be deemed revoked. 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.) 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 nify and keep harmless the City of Cupertino against liabilities,judgments, L 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 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 32647083 . 00 DATE ISSUED. . . . . . . : 10/19/2009 RECEIPT #. . . . . . . . . BS000008949 REFERENCE ID # . . . : 09100105 SITE ADDRESS . . . . . : 10285 DEMPSTER AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER PATRICK CHAN ADDRESS 10285 DEMPSTER AVE CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-1222 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 1, 100 . 00 1 . 00 0 . 00 1. 00 0 . 00 1BSEISMICR VALUATION 1, 100 . 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 2 . 00 126 . 00 0. 00 126 . 00 0 . 00 1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 253 .50 0 . 00 253 .50 0 . 00 METHOD OF PAYMENTAMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 253 .50 VISA --------------- TOTAL RECEIPT 253 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CUPERTINO ` FURNACE/AC CUPEkTINO PERMIT APPLICATION FORM APN # � U � Date: to Building Address: Owner's Name: Phone#: ��- 403 W4,qo ? z Contractor: Phone#: Fax#: Contractor License M. Cupertino Business License#: Ess I , Contact: Phone#: 40S 610 o 4 Fax #: Building Permit Info: Elect Plumb Mech ❑ Residential Commercial ❑ Job Description: For Residential Installations: Attic ❑ 1St floor 0--� 2nd 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): ..$V Imo Strapped ❑ On Platform ❑ Bonded -New Location ❑ Replacement�� Project Size: Express Standard ❑ Large ❑ Major❑ _ Valuation: lOo 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 Sum 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 1BPGAS 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. 113CBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICO Commercial Seismic B 1MRRAA 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 a- FURNACE/AC CUPE(�TINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group AIR FURN/AC CONDITIONING IBCAIRHAN Commercial A/C Units <= IOk CFM B 1 MCRAA Commercial Mech Repair/alt/add M 1 BCBSC 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 1 BPGAS For each gas piping system of 5 or P more per outlet. Comm/Resid 1 BREMAIRHAN Residential A/C units <= l 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 f IMPERMITFEE Mechanical Permit M 1 PPERMITFEE Plumbing Permit P 1 TRAVDOC Travel Documentation B 1BUSLIC Business License B INPUT ResourcLs Energy 1ADIHealth M. n oor Air ua ity an Finis es 1.Use Low/No-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 0 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 0 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0 7.Seal all Exposed Particleboard 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 1 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: 01 0 0 G:data/progs/greenbuildingguidelines/remodelers/greenpointsfinal2.12.04proteoted.xls Community Development ' 10300 Torre Avenue ' Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 XPEkTINO Building Department JOB ADDRESS: PERMIT# 102 J7 sem. Ave- 0 � ( � OWNER'S NAME: C�ONPHONE # 2- GENERAL GENERAL CONTRACTOR: FAX # I am not using any subcontractors: - 7nt4 A �l t (o l 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 'l pe Owner/Contractor Signature Date