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12010124 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10465 DEMPSTER AVE CONTRACTOR:SANDIUM PERMIT NO: 120t0124 OWNER'S NAME: PROKEY NORMAN T AND BETTY L 4223 VERDIGRIS CIR DATE ISSUED:01!1912012 OWNER'S PHONE: 4086854154 SAN JOSE,CA 95134 PHONE NO:(408)894-9072 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG I ELECT I PLUMB , 8881� µ.V. .. License Class Lie.# i �1� MECH RESIDENTIAL£ COMMERCIAL Contractor �//wngu IN► Date I Z I hereby affirmthat I erre licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE FURNACE AND DUCT WORK (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 penalh'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 fix which this permit is issued. Sq.Ft Floor Area: Valuation:$9000 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 permit is issued. APN Number:32648011.00 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 law's 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 indemnity 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 j with all noir-point source regulations per the Cupertino Municipal Code,Section Issued b Date 9.13. Signature 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: 1,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 ROOF COVERINGS TO BE CLASS"A"OR BETTER construct tine 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 37.00 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(x)should I store or handle hazardous material. I have and will maintain p'orker'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 maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety, Code,Sections 25505,25533,and 25534. €certify that in the pert6rmance of the work for which this permit is issued,I shall not employ any person in any manner sots,to become subject to the Worker's Owner Authorized ag nt: `.L Compensation laws of California. If,after making this certificate of exemption,I Date: become subject to the p'orker's Compensation provisions of ttre 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 wark'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 CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32648011 . 00 DATE ISSUED. . . . . . . : 01/19/2012 RECEIPT #. . . . . . • • • : BS000015785 REFERENCE ID # . . . : 12010124 SITE ADDRESS . . . . . : 10465 DEMPSTER AVE SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : PROKEY NORMAN T AND BETTY L ADDRESS . . . . . . . . . . : 10465 DEMPSTER AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-1224 RECEIVED FROM . . . . : YIU-HANG LEE CONTRACTOR . . . . . . . : MICHAEL LEE LIC # 28867 COMPANY . . . . . . . . . . : SANDIUh1 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 BP_L ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1 .00 41.00 0. 00 41.00 0 .00 1BCBSC VALUATION 9, 000 .00 1.00 0 .00 1 .00 0.00 1BSEISMICR VALUATION 9, 000 .00 0. 90 0 .00 0 .90 0. 00 1MFR=<100 UNITS 1 .00 130 . 00 0. 00 130 .00 0 . 00 1MPERMITFE FLAT RATE 1.00 44 .00 0. 00 44 .00 0 .00 1TRAVDOC FLAT RATE 1 .00 44 .00 0 .00 44 .00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 260. 90 0. 00 260 .90 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 260 .90 VISA --------------- TOTAL RECEIPT 260 . 90 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CUPERTINO j FEE ESTIMATOR— BUILDING DIVISION ADDRESS: 10465 dempster ave. DATE: 01/19/2012 REVIEWED BY: bobs. APN: BP#: `VALUATION: 1$9,000 PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex lex PENTAMATION FURN/AC USE: PERMIT TYPE: WORK replace furnace and duct work. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Furnace, Forced-Air 1MFR=<100 1 # $130 TOTALS: $130.00 Mech.Platt Check 0.0 hrs $0.00 Mech.Permit Fee: IMPERMIT Other R4ech.Insp. 0.0 hrs $4I Lj NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These.Les are based on the relin ina information available and are only an estimate. Contact the De t or addn'l info. FEE ITEMS �� t Rc.�,, , ,4'�5 Eff 1 i FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $130.00 PME Permit Fee: $44.00 F-1 Administrative Fee: ]ARVIN $41.00 Work Without Permit? 0 Yes Q No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 rviolion_xFe"': IBSEISMICR $0.90 Select an Administrative Item l sion Fee:: __.._.�_.......___._...__.____.___...M� IBcasc $1.00 SUBTOTALS: $260.901 $0.00 TOTAL FEE: $260.90 Revised: 1/01/2012 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: 10 45 - PERMIT# / /"Z- OWNER'S "2OWNER'S NAME: PHONE# 462 911t '1.-77- GENERAL •-7ZGENERAL CONTRACTOR:,.. BUSINESS LICENSE# ADDRESS: k, CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: /19 Signature Date Please check applicable subcontractors and complete the following information: 6/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum /Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting /Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date GENERAL PERMIT APPLICATION MEP 2 COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 (408)777-3228- FAX(408)777-3333- building(d�cupertino.orq mi-sc CUPERTINO LUMBING iv CHATIICAL /ELECTRICAL []MISCELLANEOUS PR07ECT ADDRESS10465 APN# /�Y- / OWNER NAME L PHONE Z,.b 6 8� Lt S�. 'E-MAIL STREET ADDRESS R• CITY, STATE,ZIP .I... /ti d FAX CONTACT NAME PHONE E-MAII. STREET ADDRESS CITY,STATE, ZIP TFAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT u CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER Q p 1 Y �1 LICENSE TYPE A 7.,0 BUS.LIC# SCiv�d��w b0 l (� COMPANY NAME „ E-MAIL i A.�D C� _ . COM FAX y� STREET ADDRESS J�_2 2.� V�rd+v ��Tj �(iYly CITY,STATE ZIP ` � t r' PHONE I r Q 6 4 Ci p 7, ARCHITECTIENGINEER NAME LICENSE NUMBER J Y l(/ BUS.LICL#�q0 C COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMMY PROJECT IN WIIALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK TOTAL VALUATION: R D RECEIVED BY: By my signature below,I 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 this application and the information I have provided is correct. j have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buildi onstruction`I authorize representatives of Cupertino to enter the above-id en ffied property for inspection pu@oses. Signature of Applicant/Agent: Dater SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY ❑ OVER-THE-COUNTER c ❑ EXPRESS Y U W ❑ STANDARD U ❑ LARGE a ❑ MAJOR 1EPMiscApp_2011.doc revised 06121111