11020082I CITY OF CUPERTINO BUILDING PERMIT I
IBUILDING ADDRESS: 1196 STAFFORD DR I CONTRACTOR: ALLIED AIRE SERVICE I PERMIT NO: 11020082 I
OWNER'S NAME: NEBENZAHL ELLIOTT AND LINDA A
JER'S PHONE: 4082551596
❑ LICENSED CONTRACTOR'S DECLARATION
License ClawlenSey(�--fLic.
Contractor
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.
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. 02AO
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
to building construction, and hereby authorize representatives of this city to enter
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
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature rZ:r U' Date _27F.,
v OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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.
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.
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
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.
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
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
mnify and keep harmless the City of Cupertino against liabilities, judgments,
, and expenses which may accrue against said City in consequence of the
g,anting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Date
470 S HILLVIEW DR DATE ISSUED: 02/22/2011
MILPITAS, CA 95035 PHONE NO: (408)934-8844
JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL
11
REMOVE & REPLACE FURNACE ADD A/C
Sq. Ft Floor Area: I Valuation: $6500
APN Number: 36211019.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPE ION.
Issued by: , l3( Date: l�
RE -ROOFS:
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
inspection.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air 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 Health & Safety Code, Sections 25505, 2553 and 25 34.
Owner or authorized agent: Dater
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS: /%� �"+ .
PERMIT #
OWNER'S NAME: ,J��
PHONE # S�
GENERAL CO TRACTOR: / -
BUSINESS LICENSE #
ADDRESS: C5-" old �-A A--
I CITY/ZIPCODE: - O
*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. 01
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
Owner / Contractor Signature
ate
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
ate
6 ITEMS OF 6
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 36211019.00
DATE ISSUED.......: 02/22/2011
RECEIPT #.........: BS000012753
REFERENCE ID # ...: 11020082
SITE ADDRESS .....: 1196 STAFFORD DR
SUBDIVISION ......
CITY .............. CUPERTINO
IMPACT AREA ......
OPERATOR: SylviaM
COPY # : 1
OWNER ............: NEBENZAHL ELLIOTT AND LINDA A
ADDRESS ..........: 1196 STAFFORD DR
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-4952
RECEIVED FROM ....: ALLIED AIRE SERVICE
CONTRACTOR .......: STEINER, ARNOLD R LIC # 19207
COMPANY ..........: ALLIED AIRE SERVICE INC
ADDRESS ..........: 470 S HILLVIEW DR
CITY/STATE/ZIP ...: MILPITAS, CA 95035
TELEPHONE ........: (408)934-8844
FEE ID
UNIT
QUANTITY
AMOUNT
PD -TO -DT
THIS REC
NEW BAL
----------
1BCBSC
-------------
VALUATION
----------
6,500.00
----------
1.00
----------
0.00
----------
1.00
----------
0.00
1BSEISMICR
VALUATION
6,500.00
0.65
0.00
0.65
0.00
1MFR=<100
UNITS
1.00
126.00
0.00
126.00
0.00
1MPERMITFE
FLAT RATE
1.00
42.00
0.00
42.00
0.00
1MRRAA
UNITS
1.00
63.00
0.00
63.00
0.00
1TRAVDOC
FLAT RATE
1.00
42.00
0.00
42.00
0.00
TOTAL PERMIT
----------
274.65
----------
0.00
----------
274.65
----------
0.00
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT :
AMOUNT
---------------
274.65
---------------
274.65
VOICE ID DESCRIPTION
-------- ----------------------------
505 FINAL ELECTRICAL
508 FINAL MECHANICAL
REFERENCE NUMBER
--------------------
22124
VOICE ID DESCRIPTION
-------- ----------------------------
507 FINAL PLUMBING
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
APPLIANCE / EQUIP TYPE
ADDRESS: 1196 stafford dr.
DATE.
REVIEWED BY: bobs.
UNITS
APN:
BP#:
*VALUATION: 1$6,500
PERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
#
PENTAMATION FURN/AC
PERMIT TYPE:
WORK
replace furnace at existing location add new A/C.
SCOPE
irrll/:/. Irey
APPLIANCE / EQUIP TYPE
FEE ID
t, _� . ''%_ . ! `.� < �;
QTY
UNITS
BP FEES
i.
A/C Units (<=10K cfm)
1BREMAiR
()=hcr "'c( 1,tp'Ll I
1
#
$63
Furnace, Forced -Air
1MFR=<100
irrll/:/. Irey
1
#
$126
PME Unit Fee:
$189.00
PME Permit Fee:
$42.00
C on"7Ilwction Tax
F-1
, C011S1i("cI/ R ,I, 1-'(,(
Work Without Permit? 0 Yes 0 No
$0.00
TOTALS:
T-
1 $189.00
Strong Motion Fee: IBSEISMICR
NOTE: These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 09-051 Elf. 74/10)
Mech. Plan Check 10--01hrs $0.00
t, _� . ''%_ . ! `.� < �;
? 1�Ch' k
Fmech. Permit Fee: IMPERMIT
i.
Other Mech.Insp. 0.0 hrs $42.00
t�
()=hcr "'c( 1,tp'Ll I
.1"fG:'£P hi v)' Vi'C'
�. rr. FI1 �jJ �. ('c..
/:IC'C-. jnv. /'CC,.
NOTE: These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 09-051 Elf. 74/10)
FEE
QTY/FEET
MISC ITEMS
Plan t'Iw k Fcc:
slfppf! 1'(" Fe-
PME
PME Plan Check:
$0.00
I't'1`littt I`c>c:
irrll/:/. Irey
PME Unit Fee:
$189.00
PME Permit Fee:
$42.00
C on"7Ilwction Tax
F-1
, C011S1i("cI/ R ,I, 1-'(,(
Work Without Permit? 0 Yes 0 No
$0.00
Travel Documentation Fee: ITRA VDOC
$42.00
Strong Motion Fee: IBSEISMICR
$0.65
Select an Administrative Item
Bldg; Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$274.65
$0.00 TOTAL FEE:
$274.65
Revised: 01/15/2011
CITY OF
CITY OF CUPERTINO
W I
FURNACE/AC
CUPERTIN0 PERMIT APPLICATION FORM
APN # 0 I q . C�
3tpl:Building
Date: �Z12 //
Address:
If residential, is house an Eichler? Yes ❑ No 5�- If yes, needs planning approval.
Owner's Name:
��.�/
Pghoe #:
e
Contractor, , - c _
Phone #: ��5f 3/
Fax #: C'
Contractor License #:
Cupertino Business License #:
Contact:
Phone #: 8
Fax/e-mail:
Building Permit Info:
Elect Plumb Mech R
Residential IN Commercial ❑
Job Description:
i,4 -A
((
2ri 2A
For Residential Installations:
Attic El 1A floor F -12°d floor ❑
Adhere to minimum setback requirement
For Commercial Installations:
❑
Replacement same weight ❑ Additional weight (structural calcs)
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: cro Type of Construct sage Class):
r
Strapped ❑ On Platform ❑ Bonded ❑ New Location ❑ Replacement B—
Project Size: Counter Express ❑ Standard ❑ Large ❑ Major ❑
Valuation:
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index.
Revised 12/06/1V