10100201 CITI'_OF CUPERTINO BUILDING-PERMIT'
BUILDINGADDRESS. 11553 COUNTRY SPRING CT CONTRACTOR BE PERMIT NO: 10100201
B£�£R3vftklED
OWNER'S NAME: SANJIV TANEJAN /I__� V� DATE ISSUED: 10/28/2010
bry✓NER'S PHONE: 4089730525 G!X p>oY PHONE NO:
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class-' Z-E'd Li,.#
REPLACE FURNACE AND ADD A/C
Contractor Y✓1 r2tZ7+S Date 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.declaratic ns:
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:$8675
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 APN Number:36651049.00 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 Meting WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to entc r
upon the above mentioned property for inspection purposes. (We)agree to gave 180 DAYS FROM LAST CALLEDINSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgment,
costs,and expenses which may accrue against said City in consequence of the � .(J
granting of this permit. Additionally,the applicant understands and will compl} Issued by Date:
with all non-point source regulations per the Cupertino Municipal Code,Sectior
9.18.
RE-ROOFS:
Signature /Date 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.
❑ OWNE -BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for mie 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 compens-,tion,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractor,to . HAZARDOUS MATERIALS DISCLOSURE
construct the project{Sec.70441Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 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(x)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 Cu ` lino Municipal Code,chapter 9.12 and.
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,.Section 5 5,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which thi: Owner or authorized agent-
permit is issued. -'
.I certify that in the performance of the work for which-this permit is issued I st alL
not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY
Compensation laws of California. If,after making this certificate of exemption,1
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 suchprovisions 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.1 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 re ating
to building construction,and hereby authorize representatives of this city to en er
� -n the above mentioned property for inspection purposes.(We) is
to save ARCHITECT'S DECLARATION
nnify and keep harmless the City of Cupertino against liabilities,judgments,
V,vats,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 compl
with all non-point source regulations per the Cupertino Municipal Code,Sectic n Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: `VALUATION: 1$8,675
xPERMIT TYPE: Mechanical Permit I LAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: / t.i� '< ir�`,�; : PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
A/C Units (<=10K cfm) 1BREMAIR 1 # $63
Furnace, Forced-Air 1MFR=<100 1 # $126
TOTALS: $189.00
Mech.Plan CheckO.p hrs $0.00
Mech.Permit Fee: IMPERMIT
Other/Mech.Insp. rO.0 I hrs $42.00
1`t'c I r _ J 1 r 'f. jfi4t
NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn 7 info.
FEE ITEMS (Fee Resohation 09-051 Ef 'i1-'Ill F]4E QTY/FEE MISC ITEMS
Platt Check Fcc_
PME Plan Check: $0.00
I)erinit Fc,c
Stapp/, hl,s,/)I'
PME Unit Fee: $189.00
PME Permit Fee: $42.00
C on5ovc!ion f clx
1couslictal Rc vic o,
Work Without Permit? 0 Yes E) No $0.00
Travel Documentation Fee: ITRA VDOC $42.00
i
Strong Motion Fee: 1BSEISMICR $0.87 Select an Administrative Item
Bldg;Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $2'74.87 $0.00 TOTAL FEE: $274.87
Revised: 10/17/2010
v
CITY CF CUPERTINO
7 ITEMS OF 10 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Elk: Lot:
APN 36651049 . 00
DATE ISSUED. . . . . . . : 10/28/2010
RECEIPT 4 . . . . . . . . . ES000011863
REFERENCE ID # . . . : 30100201
SITE ADDRESS 3.1553 COUNTRY SPRING CT
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER SANJIV TANEJAN
ADDRESS :.1553 COUNTRY SPRING CT
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . JEFF RAINEY
CONTRACTOR -BD - TO BE DETERMINED LIC # 00096
COMPANY "BD - TO BE DETERMINED
ADDRESS . . . .
CITY/STATE/ZIP . . .
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- -------------
---------- ---------- ---
1BCBSC VALUATION 8, 675 .00 1 . 00 0 .00 1 . 00 0. 00
1BSEISMICR VALUATION 8, 675 . 00 0. 87 0 .00 0 . 87 0 . 00
1BUSLIC FLAT RATE 1 . 00 114 . 00 0 . 00 114 . 00 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 388 . 87 0 . 00 388 . 87 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
CITY OF
CITY OF CUPERTINO
FURNACE/AC
CUPERTINO PERMIT APPLICATION FORM
APN# ob Date:
Building Address:
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Owner's Name: Phone#:
T
Contractor: Phone#:
Fax #:
Contractor License M Cupertino Business License#:
Contact: Phone #: 2 7 5
Fax #: ? j 5 'C
Building Permit Info: 2����� ii r�ti��{ �� 1��►c l�L.4 'tic>,�J, l i t I� %> lc_-', 5
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�'17(� NL"t� /17L. � /G ..v, � � 7C'Z 1�1 Z37, il--w1/7 7c� �=t��•./1)c: �hc,Z. ��-17 Ic=Z..4�'1C.7 ,,� ��'�
Elect ® Plumb ❑ Mech
Residential Commercial ❑
Job Description: Zc=7Q.j-,f-t AX _
For Residential Installations:
Attic F_] I" floor 2"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: G 7 S Type of Construction.-Wsage Class):
Strapped ❑ On Platform� Bolded 0 New Location Replacement [ —
Project Size: Express Eq"'"STa—ndard ❑ Large ❑ Major ❑
Valuation:
Green Building: Please complete relevant portion of the Green Building Checklist& attach it to the
application or if applicable, ic.clude in plan set & the sheet index.
Revised 01/07/09