09110098 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21175 GARDENA DR CONTRACTOR:PERFORMANCE AIR PERMIT NO:09110098
SERVICE
'''NER'S NAME: MEEHAN THOMAS F ET AL 1805 LITTLE ORCHARD ST DATE ISSUED: 11/18/2009
(,vvNER'S PHONE: 4085948347 SAN JOSE,CA 95125 PHONE NO:(408)920-6170
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lie.# MECH r RESIDENTIAL COMMERCIAL r
Contractor Date
JOB DESCRIPTION:REPLACE FURNACE
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. Sq.Ft Floor Area: Valuation:$1852
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
APN Number:32608063.00 Occupancy Type:
permit is issued.
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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building constriction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify 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
with all non-point source regulations per the Cupertino Municipal Code,Section Issuedy�''�.
9.18.
S; +ture 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:
I,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)
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,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
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 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
perfonnance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker'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.
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 Owner Pu rite it:
Compensation laws of California. If,after making this certificate of exemption,I Date:
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. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work'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
V he above mentioned property for inspection purposes.(We)agree to save
i, nify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the
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
oe
Signature Date
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32608063 . 00
DATE ISSUED. . . . . . . : 11/18/2009
RECEIPT #. . . . . . . . . BS000009218
REFERENCE ID # . . . : 09110098
SITE ADDRESS . . . . . : 21175 GARDENA DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : MEEHAN THOMAS F ET AL
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1617
RECEIVED FROM . . . . : SHAUN H CHEN
CONTRACTOR . . . . . . . : TIM STANFORD LIC # 27768
COMPANY . . . . . . . . . . : PERFORMANCE AIR SERVICE
ADDRESS . . . . . . . . . . : 1805 LITTLE ORCHARD ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408) 920-6170
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 1, 852 . 00 1 . 00 0.00 1 . 00 0 . 00
1BSEISMICR VALUATION 1, 852 . 00 0 .50 0. 00 0 . 50 0 . 00
1EPERMITFE FLAT RATE 1. 00 42 . 00 0. 00 42 . 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
1PPERMITFE FLAT RATE 1. 00 42 . 00 0. 00 42 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 190 .50 0 . 00 190 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 190 .50 #1145
---------------
TOTAL RECEIPT 190 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
09r vC) 9 k
CITY OF CUPERTINO
FURNACE/AC
CUPS Of
PERMIT APPLICATION FORM
APN # Date: I �b
Building Address: � ^ • /� �, `
Phone#:
Owner's Nam � C�
Arfil,t
Phone#:�� - s� �/�-7.0
Contract r: � / !
��Cwe- A`y- Fax#:
Contractor License#: Cupertino Business License#:
Phone#.
Contact:
GVt Vl Fax#:
Building Permit Info:
Elect Plumb [-�� Mech
Resi ntial Commercial ❑
Job Description:
For Residential Installations: 2°d floor [
Attic ❑ 1 Sc floor ❑
Adhere to minimum setback requirement ❑
For Commercial Installations:
Additional weight(structural calcs) ElReplacement same weight El
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction (Usage Class):
Strapped ❑ On Platform ❑ Bonded
New Location Replacement
Project Size: Express �, Standard�6 Large❑ Major❑
Valuation:
Green Building: Please complete relevant portion of the Green Building Checklist & a ch it to the
application or if applicable, in
in plan set & the sheet index.
Revised 01/07/09
CITY OF CUPERTINO
FURNACE/AC
CUPEI�TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1MRAPPVNT Residential for the install/relocate/or M
replacement of ea appliance vent
install ¬ incl in an appl permit.
FURNACE FURN/AC
1PGASRES Residential for ea gas piping system of P
1-4 Outlets
1 BPGAS For each gas piping system of 5 or P
more per outlet.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Residential Seismic B
1 MECPLNCK Mechanical Plan Check M
1MFR=<100 Furnace Syst<=100k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance up to and
include 100,000 Btu/h
1MFRN>100 Furnace Syst> 100k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance over
100,000 Btu/h
1 EPERMITFEE Electric Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit P
1 TRAVDOC Travel Documentation B
1BUSLIC Business License B
M.1ndDDr Air Quaft and Finishes
1.Use Low/%-OC Paint 1 IAD/Health pts y--yes 0
2.Use Low VOC,`,eater-Based Wood Finishes 2 IAC VHealth pts y--yes 0
3.Use Lovdblo VOC Adhesives 3 IADJHealth pts y=yes D
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes D
5.Use Engineered Sheat Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes 0
6.Use Exterior Grade Ply wood for Interior Uses 1 IACYHealth pts y=yes 0
7.Seal ail�t otebaard or MDF 4 IAD/Health-pts Y:-:Yes
B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes D
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes D
10.Install Whole House Vacuum System 3 IADMealth pts y--yes0
i 1 1
N.Flooring
1.Select FSC Certified Wood Flooring B Resource pts y=yes 0
2.Use Bapidly Beneawabie Flooring Materials 4 Resource pts y=yes D
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes D
4.Install Natural Linoleum in Place of Vinyl . 5 IATHealth pts y=yes D
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
5.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
1 1 s
Total Points Available: 140 130 57
Total Points Project Received: 1 01 01 D
exe
G:datalprooslgreenbuildngguidelines/ramodslerslgreenpointsfinal212Mproteoled.xls
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS:
PERMIT #
OWNER'S NAME: PHONE
GENERAL CONTRACTOR: ,Y 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
F---] Tile
Owner/Contractor Signature Date