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12020056 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7955 WOODLARK WAY CONTRACTOR:MUSIAL'S HVAC PERMIT NO: 12020056 OWNER'S NAME: SHAIKH KARIMULLA AND PAGADIPAALA JA 5945 SUNROSE AVE DATE ISSUED:02/13/2012 OWNER'S PHONE: 408996 1 5 5 3 NEWARK,CA 94560 PHONE NO:(877)579-3075 ❑ LICENSED CONTRACTOR'S DECLARATION )._ BUILDING PERMIT INFO: BLDG 'm ELECT _. PLUMB License Class Lie.# S,-3k- .0 25!rL ��p MECH RESIDENTIAL ` COMMERCIAL Contractor r 1►^n LIDS-rAcIl,S TJI!h(/,Date 1 I hereby affirm€that I amlicensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE FURNACE AT SAME LOCATION (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:$4000 I have:and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of die work for which this permit is issued. APN Number:36203021.00 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 laws 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. i 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 with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: Date: Signature Date 13 la 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 C'ontractor's License Law for one of inspection. the following two reasons: 1,as owner of tine 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) 1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(See.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& performance 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 prodded for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,t6r the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District l will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Owner authori d a Compensation laws of California. If,after making this certificate of exemption,I _ Date: become subject to(fie 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<md 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 tare Cupertino Municipal Code,Section 9.18• Licensed Professional Signature Date CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ` ADDRESS: 7955 woodlark way. DATE: 02/13/2012 REVIEWED BY: bobs. APN: BP#: VALUATION: $4,000 PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition /Repair PRIMARY AFD or Du lex PENTAMATION FURN/AC USE: p PERMIT TYPE: WORK replace furnace too same location. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Furnace, Forced-Air 1MFR=<100 1 # $130 TOTALS: 1 $130.00 Mech.Plan Check 0.0 hrs $0.00 Mech.Permit Fee: IAIPERMIT Other R-tech.Insp. OA hrs $44.00 Ll JVOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . These ees are based on the relimrna information available and are o!!lL an estimate. Contact the De t or addn'1 info. FEE ITEMS = t t 1 c.3 iyn;on 11-053 tz ' 1 1.1) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $130.00 PNIE Permit Fee: $44.00 Administrative Fee: IADMIN $41.00 Work Without Permit? © Yes 0 No $0.00 Travel Documentation Fee: 1TRA VDOC $44.00 LIf�i �:'ior$) ;Fe W. IBSEISAIICR $0.50 Select an Administrative Item Ply4I {°� isicn I? e: IBCBSC $1.00 SUBTOTALS: 1 $260.50 $0.00 TOTAL FEE-.T $260.50 Revised: 1/19/2012 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: "?q!5-5 W p 0 W4%4. PERMIT# Q OWNER'S NAME: Amo 01, 1 PHONE# -17'-,5"?q7— 3 S GENERAL CONTRACTOR: O-ST L S BUSINESS LICENSE# ADDRESS: _6qq5Q,DSL P. CITY/ZIPCODE: �wGr�. C4- Sfs *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SU CONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Sig ature Date Please check applicable subcontractors and complet the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum/Wood .12 lass / Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile ,\AAP a � a Owne /Contractor Signature Date GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE -CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333- building(d,)cupert no.org MISC []PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS OWNER NAME Y �r, V' 1 0� ,a a�( L PH "W 6q t.' E-MAIL STREET'ADDRESS CITY, STATE,ZIP �! FAX CONTACT NAME1 C,r w\ (l C �l PHONE.Q�^ 41 E-MAIL STREET ADDRESS 4` J CITY,STATE{ ZIP FAX WNER ❑ OWNER-BUILDER ❑ OWNER AGENTCONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME V S�V4' S Q LICENSE NUMBER -"LI \-v • ' O� LICENSE TYPE BUS.TSC# COMPANY NAME '► ` / 1 E-MAIL "� _G F 1310- LVH*-12,0q STREET ADDRESS.6,jq5 �C)w 66t CITY,STATE ZIP 4,1 '/ /� qq6(&o PHONE �^��'��7S ARCHITECT(ENGINEER NAME LICENSE NUMBER IL- (/� BUS.LIC# r COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ffSFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK C ��C iQ Q CIA^1 f , TOTAL VALUATION: D. iC)O 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 wit all applicable local ordinances and state laws relating to buil ' g constructionb uthorize representatives of Cupertino to enter the abGve-idintif property for inspection pu{poses. Signature ofAppl cant(Agent: Date: SUkV,ENENTAL VFORMATION REQUIRED OFFICE USE ONLY THE-COUNTER a ❑ EXPRESS Y U w ❑ STANDARD U ❑ LARGE ❑ MAJOR AHPMrscApp_2011.dac revised 06/21/11