13050040 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10445 WESTACRES DR CONTRACTOR:PELLE HEATING&AC INC PERMIT NO: 13050040
OWNER'S NAME: ANIL LOHIYA 3751 D CHARTER PARK DR DATE ISSUED:05/06/2013
OWNER'S PHONE: 4084461177 SAN JOSE,CA 95136 PHONE NO:(408)978-7060
❑ LICENSED CONTRACTOR'S DECLARATIONr—
�D� �� BUILDING PERMIT INFO: BLDG "'"` "`�ELECT PLUMB
License Class( Lic.# T_
A MECH RESIDENTIAL COMMERCIAL
Contractor{)� .Date .
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALL NEW A/C UNIT AT SIDE YARD
(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:$4875
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. APN Number:35914030.00 Occupancy Type:
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
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 Issued b Date:
9.18.
Signatu Date
RE-ROOFS:
❑ 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:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
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 ALL RO&--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
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.
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
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's er or auth ' . agent:
Compensation laws of California. If,after making this certificate of exemption,I Date:4
6
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
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
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
Signature Date
:'.GENERAL PERMIT APPLICATION
MIER -*
i COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•buildingCaD-cupertino.oM MIS C
CUi�ERTi1N0
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PROJECT ADDRESS APN#
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CONTRACTOR NAME LICENSE LICENSE BUS.LIC#
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USE',OF i I' 1 of DUPLEX 1..; 0'MULTI-FAMILY PROTECT IN WMDLAM ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BLJII,.DING ❑COMMERCIAL. "r URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
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By iriy slgnatue below,„certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read flus
applicarioti and;t�}e ullo oration I have"r vided is correct. I have read the Description f rk and verify it is accurate. I agree to complylwith all applicable local
ordinances and sate laws relatingit uil ' g c ction. I authorize r senta' upertino to enter the above-id ntifred roperty for inspection purposes
Signature ofAp�LCant/Agen I'_ Date:
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PLEMENTAL INFO TION REQUIRED
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MEPMiscApp 2011.doc revised 06/21/11
I I!I Il 1 I ;'I I•
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10445 westacres dr.. DATE: 05/06/2013 REVIEWED BY: bobs.
APN: BP#: VALUATION: 1$4,875
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: PERMIT TYPE: A
wORK install new a/c unit at side yard.
SCOPE -
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
A/C Units (<=10K cfm) 1BREMAiR 1 # $67
TOTALS: ,`; r $67.00 -r
d
Mech.Plan Check "00 $0.00 Plumb,Plan Check Elec.Plan(,heck
Mech.Permit Feer IMPERMIT Plumb,Permit Fee; Elec, Permit Fee:
LOther Mech.Insp. 0.0 hrs $45.00 Other Plumb Insp, Other-Elec.Insp. Li
h.Insp.Fee Plumb. Insp.Fee: Elec.Insp.Pee:
NOTE:This estimate does.not•include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These Aes are based on the prellndna.. information available and are only an estimate. Contact the De t or addn 7 info.
FEE ITEMS(Fee Resolution 11-053 Eff. 711112) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC.I'ee
PME Plan Check: $0.00
erintt Fee:
1'
Supp1. .Insp FC
PME Unit Fee: $67.00
PME Permit Fee: $45.00
Construction :Tax:
Administrative.Fee: IADMIN $42.00
Work Without Permit? 0 Yes No $0.00
Advanced PlanningFees:
Travel Documentation Fee: ITRAVDOC $45.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldy Stds Commission Fee: 1BCBSC $1.00
;a = $200.50
0.00z$200.50 $
Revised: 04/29/2013
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MAY 0 6 2013