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15050147 (3) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22361 SANTA PAULA AVE CONTRACTOR:CA MECHANICAL INC PERMIT NO:15050147 OWNER'S NAME: VIPIN SAMAR 2227 AMERICAN AVE DATE ISSUED:05/22/2015 OWNER'S PHONE: 4082530595 HAYWARD,CA 94545 PHONE NO:(510)732-7771 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL W y INSTALL(N)A/C UNIT IN SIDE YARD AREA License Class Lic.# Contractor / Date a 2`f 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. Sq.Ft Floor Area: Valuation:$9498 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:35704058.00 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 to comply with all city and county ordinances and state laws relating WITIHN 180 DAYS OF T 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 DAY LAS LED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, Date- costs,and expenses which may accrue against said City in consequence of the S 2 Z ! granting of this permit. Additionally,the applicant understands and will comply slued b Date: with all non-point source regulations per the Cupertino Municipal Code,Sectio 918. j. ROOFS: any r Signature ..� Date All roofs shall be inspected prior to y roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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) I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505 3,and 25534. Section 3700 of the Labor Code,for the performance of the work for which thisrt: Owner or authorized agent permit is issued. Date: .- I 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address — 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,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 GENERAL PERMIT APPLICATION 0\ MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 Apok 0% +CUPERTIN© (408)777-3228• FAX(408)777-3333 •build!ngCc)cupertino.org M15 ❑PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESSAPN OV.NTERNANE E-MAIL 31~rs`7 STREET ADDRESS CITY, STATE,ZIP FAX CONTACT NAME/"A E-MAIL ST ET ADD SS G� / CITY,STATE, ZIPTFAX ❑ ONINTER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR 6 CONTRACTORAGEATT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR LICENSE ER j LICENSETYPE BUS.LIC 4 L C COMPANY AT E-MAIL ,/ FAX � ec rcca ST ET ADDRESS CITY,STATE,ZIP P 0 cr r'7en` Gc 6� d ARCHITECT/ENGINTEER NAME LIC SE NUMBER BUS.LIC n COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BI=DAG: E]COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLERHOME? ❑ NO DESCRIPTION OF WORK TOTAL VALUATION: 4 + t By my signature below,I certify to each of the following: I am the property owner or authoriz e property ow b f. I have read this application and the information I have provided is correct. I have read the Description of Work a lerify it is accurate. I e omply with all applicable local ordinances and state laws relating to building cons ibh. I authorize represent,Rtiues of Cupertino to enter the above-idre�nh ed property fo"r inspection purposes. Signature of Applicant/Agent: Date: s " r ENFML- INFORMATION REQUIRED r Yfl rx ' ❑ XPI2ESS � n3 'w'�v, . M WON�AM Y a� 3 � •:��31lAJOR��'�c��� �z %� �; A7EPMiscApp_201].doe revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 22361 SANTA PAULA AVE DATE: 05/22/2015 REVIEWED BY: MELISSA APN: 357 04 058 BP#: *VALUATION: 1$9,498 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/Repair PRIMARY SFD or Duplex PENTAMATION FURN/AC USE: p PERMIT TYPE: A WORK INSTALL N A/C UNIT IN SIDE YARD AREA SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES A/C Units (<=1 OK cfm) 1BREMAIR 1 # $72 TOTALS: 5 $72.00 Mech.Plan Check 0.0 hrs $0.00 Plumbs Plan Check Elec..Plan Check Mech.Permit Fee: IMPERMIT Plumb. hermit Fee: Elec. Permit Fe FOther Mech.Insp. 0.0 hrs $48.00 0/her Plumb Insp. Other L lec.Insp. Insp. hese: Plumb, Insp. Fee: Elec.Insp.Pine: NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These ees are based on the prelimina information available and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13) FEE QTY/FEE MISC ITEMS /Tern Check Fee: Suppl. .P("'Fee PME Plan Check: $0.00 Permit Fee: Suhpl, Insp Fee PME Unit Fee: $72.00 PME Permit Fee: $48.00 Construction Tax: F Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning Fees: Travel Documentation Fee: ITRAVDOC $48.00 A Strong;Motion.Fee: IBSEISMICR $1.23 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 m SUBTOTALS ~ $215.23 $0.00 TOTAL FEE: $215.23 Revised: 05/07/2015 Sco�C= ADI?-- .tJE-7-, TD Sioe 4 A r- riav - MAY 22 2014 •l .I PLOT PLANS CNE BY q DATE S-2 i - tt= */ 'liepL , ,gNNING F 9 CUPERTINGI�A VC- T 0/1 COM ,UNITY � ETENT B ILDIN;�DIVo CUPERNO Y. ,• _ __ pt }APPROVED 3a This se of plans and specifications NJUST be kept at the u lob sit during construction. It is unlawful to make any r . chan es or alterations on same, or to deDaae therefrom,without approval from the Building The S'amping of this plan and specl. The of the ns vLotatioT be he.d to permit or to b f ce or State Law. _- of ami r DATE PERMIT# `��—