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06100160 CITY OF CUPERTINO BUILDING DIVISION PERMIT 0R� �� "' BUILDING ADDRESS: AAA FURNACE & AIR GOND I T I WNT. 06100160 22686 MEDINA CT PERMIT ISSUE DATE OWNER'S NAME: SHIRIN HASAN 1712 SANTTARY NO. CONTROL NO. )NE: (408) 293-47.1,7 BUILDING PERMIT INFO ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH O p LICENSED CONTRACTOR'S DECLARATION Job Description V I hereby affirm that I am licensed under provisions of Chapter 9(commencing z with Section 7000)of Division 3 of Ute Business and Professions Code,and my license is =y in full force and f{e L L� ��d'�� REPLACE FURNACE & ADD A/C v�z License Class t p Date - Contractor - ARCHITECTS DECLA T O i a< I understand my plans shall he used as public records 1U1 ' U.F Licensed Professional h.< OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractors License Law for the :00 following reason.(Section 703 1.5.Business and Professions Code:Any city or county m which requires a permit to concoct,alter,improve,demolish,or repair any structure nno prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation othat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area h (commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.3 by any applicant for a permit subjects the applicant to a civil penalty of 3APUIR I: 0 0 Occupancy Type not more than five hundred dollars($500). ❑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 Required Inspections and Professions Code:The Contractor's License Law docs not apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale.If, i however,the building or improvement is sold within one year of completion.the owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- ccnse Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. ❑I am exempt under Sec. B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: �]1 have and will maintain a Certificate of Consent to self-insure for Worker's Compcn- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number arc:_ Cartier.zi r e 6 d w Policy No.: � ETITIMATOOF EXEMPTION FROM O CRS' COMPENSATION INSURANCE (Phis section need not be completed if the permit is for one hundred dollars($100) or less.) 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 Workers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must Z forthwith comply with such provisions or this permit shall be deemed revoked. Z O CONSTRUCTION LENDING AGENCY E~-r 4 1 hereby affirm that there is a construction lending agency for the performance of (x> the work for which this permit is issued(Sec.3097,Civ.C.) (7a QLendcr's Name az Lenders Address U C) I certify that I have read this application and state that the above information is LL►� correct.I agree to comply with all city and county ordinances and state laws relating to 0 U building construction.and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes. GL (We)agree to save,indemnify and keep harmless the City of Cupertino against ,E"y liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. Date rUi rLJ`�' �+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 2ignature E ULATIONS. C Re-roofs of pylic t/Comractor IDIRC HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes o Will the applicant or u(tore building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove ..mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes No 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505.25533 and 25534.I understand that if the building docs not currently have a tenant,that it is my responsibility to notify the occupant of the uimmcnts which must be met prior to issuance of a certificate of Occupancy. Signature of Applicant Date mtvr / io 1z-Pi All roof coverings to be Class"B"or better Imner'da7uthorize'd agent Date CITY OF CUPERTINO 3m 1 of 1 PERMIT RECEIPT OPERATOR: amyw COPY # : 2 Sec : Twp: Rng: Sub: Blk: Lot : APN 34215056 . 00 DATE ISSUED. . . . . . . : 10/23/2006 RECEIPT # . . . . . . . . . : 36522 REFERENCE ID # . . . : 06100160 SITE ADDRESS . . . . . : 22686 MEDINA CT SUBDIVISION . . . . . . CITY . . CUPERTINO IMPACT AREA . . . . . . . OWNER SHIRIN HASAN ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , RECEIVED FROM . . . . : JIM RANDO CONTRACTOR . . . . . . . : RANDO, JIM LIC # 8050 COMPANY . . . . . . . . . . : AAA FURNACE & AIR CONDITIONING ADDRESS . . . . . . . . . . : 1712 STONE AVE CITY/STATE/ZIP . . . : SAN JOSE, CA 95125 TELEPHONE . . . . . . . . : (408) 293-4717 FEE 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 7, 000 . 00 0 . 70 0 . 00 0 . 70 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 . 44 0 . 00 176 . 44 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER - - - - - -- - - - --- - - -- --- - ------- - ----------- - ------ OTHER 176 . 44 VISA TOTAL RECEIPT 176 . 44 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ------------- 301 ROUGH PLUMBING 303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CUPERTINO o tOCdl lQ0 FURNACE/AC CUPU-kl INO PERMIT APPLICATION FORM APN# 3L�2 l V Date: Building Address: Owner's Name: Phone#: Contractor: Phone: License#: Contact: Phone: Cupertino Business License#: Building Permit Info: Bldg ❑ Elect -E] Plumb ❑-'� Mech fT Job Description: ( _ L 6 c, c. Residential 0 Commercial ❑ For Residential Installations: Attic ❑ 1 sc floor 9 2°d floor❑ Adhere to min set back requirement For Commercial Installations: Replacement same weight ❑ Additional weight (structuralEl calcs) Structural Calculations required for new installation El New installation Planning Approval Required ❑ Cost of Project: Type of Construction: Occupan�^�p Strapped ❑ On Platform Bonded Sq.Ft. Floor Area: New Location Replacement Qty. if Applicable Fee ID Fee Description Fee Group BENERGY Energy BUILDING BREMFURN Furnace MECHANICAL BREMACOVER A/C Unit> 10,000 e n MECHANICAL BREMAIRHAN A/C Units <= 10, 000 cfin MECHANICAL / BREMRECEPT Recptl, 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