06090019 CITY OF CUPERTINO �' `�•�* '^�'�' • • " � -
a'lu1LDINC.DJVIs1oN
PER MITO1�IRQi. TC?RII 'FOR�IA.� Q1V" '
BUILDING ADDRESS: CONDITIONED AIR PERMIT No.O6O9OO19
22434 PALM AV
OWNER'S NAME: PERMIT ISSUE DAM
MANGY BHATTACHARYYA 1701 LITTLE ORCHARD ST
E: SANITARY NO, CONTROL NO.
(408) 291-2220
ARCHRECf/ENGINEER: BUILDING PERMIT INFO
t� t� PLUMB
I� MECH
tn
�op LICENSED CONTRACTOR'S DECLARATION Job Description
1^� I hereby affirm Net 1 am licensed under provisions of Chapter 9(Commencing
P
with Secdon7IX ffDivlelon3 of the Business and Professions Code,and my license is
mruOTen, t REPLACE FURNACE ADD .A/C
z Lianan❑ Lico.
Contrxcmr -
Qq ARCHfiECTS DEC A
a 1 understand my plans mall W mind as public retards
)a
sop Licenced Professional
OatNEm exempt
DER DECLARATION
I hereby.(lice that 11. exempt from the Contractors :My Law for the
po followingorma emits 7amisr Business and vx fdecull Code:Any city or County
i$
which is Wo a permit re Cares the altar.improse,de Permit
t o repair any stmnum $8550
paorm its lensed pursuant 1,
1,the provuhTcant then mehperit toftmasLaw(Ch emem Valuation
< (that he commencing with Setion700)9Divions3.fdh.cif then usimr'andprQssion. upmr9 Sq. Ft. Floor Area
l�� tat he Is exempt
healon 70W the basis f r th the B ed exam d es.Any
Cade)of
Nat W u emmpt dert(mm and de bum for the alleged examples.Any vmudm of
section 7031.5 by any applicant for a Permit subjects the applicant to a civil Family of t V U Occupancy Type
not more don five buMred dollars(SSW).
❑1,u Owner of the property,Or MY employees with-gas u deb mm=Pensadon,
win do the work,and use sbucum isnot Intended 0r offered roraales(Sm.7044,Business Required Inspections
and Profession Code:The Commutes Litems law does not apply m an owner of q P
property who builds or improv dercon,end who does such work himmif or through his
own corpl^ycea,provided dnsuch improvements are eu tmandcd oroaered forsale.IL
however.the building or improvsmmt Is to within mesa year of cumpledon,the Owner-
builder win have the burden of proving Chat W did rt Wim m beprova for purpose Of
sale.).
❑L Ca Owner Of site property,am exclusively contracting with licensed comm chum In
Construct the project(Sec.7044,Business and Professions Code:)The contractors Li-
come law dots not apply m an owner of property who WIWs or improv demon,and,
who conuacu for such projects with aeonmecter(U licensed pursuant in doe contractor's
License law.
❑lumuemplumemsee .BAPCforthisramn
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby amrm under Penalty of perjury nn of the following declarations:
I have and will mainuio a CeN6am of Consent in u161mum for WorkersCompen-
,me^,u provided fn,by Sectio^37W of she labor Code.fm the perfomsea of the
work for which this pmmft is issue,[.
❑1 have and will maintain Workers Compensation btsurance,u required by Section
3700 of the labor Code,for tae performansu of the wank for which this permit is Wood.
My Worker, Policy
„C��o��mpensation InsuMAaL2race�c mics soil Policy number art:
Cyder. n1nCEATIFICA O
TE F E7(Eh13r1OFROM ORKERS' j
COMPENSA71ON INSURANCE
ribu section nerd no teccomputed if Che perm bfaone hundrddo0an($100)
or less)
1 certify that in the performance of site work ter which this Form,H leaned.I shall rant
employ any person in my mesmerist u in become subject in tite Workers'Competuuim
Laws of California.Data
Applicant
NOTICE TO APPLICANT.If,after mating thisCenifinu of Emosp ion,you should
became subject to the Warless Compensation provisions of the ladar Code.you mum
0 forthwith comply with men provisions or this peril shall W deemed revoked.
z
tiCONSTRUCTION LENDING AGENCY
'ren 1Wmbyaffirm that dere is consurmtro lending agency four on,performance of
UI site work for which this permit is umrd(Sec 3097.Civ.C)
QUndoes Name
Z)z fender,Addmas
U Q 1 certify,Nat I have read thin application and Nm Nu the move inr0hold n is
U. i~ coma.I agree to comply with all city and county ordinances and state laws mla0fig to
0UWilding Construction,and hereby authorim representatives of this city to enter ulum the
W above-mentioned property for inspection purposes.
py (WC)agree to Cave.indemnify and)rep harmlm the City of Cupertino against
nFi rA liabilimea judgmcnta.eomu and tapetum which may In any my amts against said city
in comeemoux:or the ginimul0j,Of U APP IL CANT UNDERSTANDS A1ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO •REGULATIONS. - -
&4 9/DS 10 6' Re-roofs
Si ofAppica ct Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the male s or future Wilding oa:upmtstore orhandle haxardous material
as defined by me Cupertino Municipal Code.Chapter 9.17,and the Haldt and Safely
Cade,Section 75532(a)7 All roofs shall be inspected prior to any roofing material being installed.
11 Y0241-ou Will de applicant or future Wilding Occupant tau equipment ordevica which If a roof is installed without first obtaining an inspection,I agree to remove
emit hsCallon air coetamirunts as defined by the Bay Ara Air Quality Management all new materials for inspection.
D rittT
❑Yes
I have mad the Wearduu material requirements under Chapier6.95ofthe Califon
nim HCSlth&Saf0tyCede,Sec6ons 75505,75533 am125534.I understand thulfthe building
does not cumntly have a unane that It u my maponsl611ity to notify theWmceoccupant of de
menu which must be arm uoracmfiricateof Occupancy' Signature of Applicant Date
I/63/0'cAll roof coverings to be Class"B”or better
r or mtnam d c Dam
CITY OF CUPERTINO
!m 2 of 2 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . I . . . . : 35704042 . 00
DATE ISSUED. . . . . . . : 09/05/2006
RECEIPT # . . . . . . . . . : 35899
REFERENCE ID # • : 06090019
SITE ADDRESS . . . . . : 22434 PALM AV
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : MANOY BHATTACHARYYA
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : CONDITIONED AIR
CONTRACTOR . . . . . . . : RICHARD READ LIC # 22334
COMPANY . . . . . . . . . . : CONDITIONED AIR
ADDRESS . . . . . . . . . . : 1701 LITTLE ORCHARD ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408) 291-2220
EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BREMAIRHAN NO.UNITS 1 . 00 10 . 26 0 . 00 10 . 26 0 . 00
BREMFURN NO UNIT 1 . 00 14 . 31 0 . 00 14 . 31 0 . 00
BENERGY PERMIT FEE 1 . 00 34 . 86 0 . 00 34 . 86 0 . 00
BREMRECEPT NO. OUTLETS 1 . 00 1 . 20 0 . 00 1 . 20 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
BSEISMICRE VALUATION 8, 550 . 00 0 . 90 0 . 00 0 . 90 0 . 00
EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
MPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 176 . 64 0 . 00 176 . 64 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- --------- --- ------------------
OTHER 352 . 88 VISA
TOTAL RECEIPT 352 . 88
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-----------------
-------- -----------
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL
•
F Community Development
10300 Torre Avenue
;�� ✓' Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
WUPERTINO
Building De artment
JOB ADDRE PERMIT #
aa.y 34 (M 6 d jao / %
OWNER'S NAME: fnM 0 Q CL PHONE # •q - t4
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
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
Tile (�
d 24 Ao
er/Contra or Signature Date
CITY OF CUPERTINO �y cnool
%C
FURNACE/AC W1
OUPERTINO PERMIT APPLICATION FORM
APN# a� Date:
Building Address: 1
aa4a� �.l
Owner's Name: Phone#:
L
l3 r
Phon : Lic ns on r aL 8 olac aaa0 Lsl (0a-�
o tact: hone: Cupertino Business License#:
t(e o -a9r-aa
Building Pe it Info:
Bldg ❑ Elect 661— Plumb ❑ Mech C29--j
ob Descripti C
Ce • e
Residential Commercial ❑
For Residential In llations:
Attic ❑ I" floor 2"d floor❑
Adhere to min set back re uiremen
or Commercial Installations:
Replacement same weight E] Additional weight(structural calcs) ❑
Structural Calculations required for new installation
New installation Planning Approval Required ❑
Cost of Projec • Type of Construction: Occupancy group:
Strapped LJ On Platform Bonded Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
A licable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfin MECHANICAL
BREMAJRHAN A/C Units<= 10, 000 ctin MECHANICAL
BREMRECEPT Reepti, Switch &Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BPGAS Gas Piping System Fee PLUMBING
BUSLIC Business License BUILDING