10110116 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22240 VARIAN WAY CONTRACTOR:ATLAS-TRILLO HVAC PERMIT NO: 10 110 116
OWNER'S NAME: SHANKAR 1965 KYLE PARK CT DATE ISSUED: 11/17/2010
OWNER'S PHONE: 4089814594 SAN JOSE,CA 95125 PHONE NO:(408)286-8931
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
/ 11 REMOVE AND REPLACE EXISTING FURNACE IN SAME
�m :;n
License Class LkwL .# LOCATION
Contractor Date
1 hereby affirm that I am ' ensed 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: Sq.Ft Floor Area: Valuation:$3500
t. 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 APN Number:32617043.00 Occupancy Type:
performance of the work for which this permit is issued.
2. 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
permit is issued. PERMIT EXPIRES IF WORK IS NOT STARTED
APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR
I certify that I have read this application and state that the above information is 180 DAYS FROM LAST CALLED INSPECTION.
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,and her orize representatives of this city to enter y L�
upon the above mentrAdd* ection purposes. (We)agree to save Issued bye
indemnify and kegp pertino against liabilities,judgments,
costs,and pe es Cil
nst said City in consequence of the
granting of is pepplicant understands and will comply with RE-ROOFS:
all non-poi t sour ertino Municipalde Secti-Mik.18.
All roofs shall be inspected prior to any roofing material being installed.If a roof is
l
Signature Date installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
OWNER-BUILDER DECLARATION Signature of Applicant: Date:
eby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
the following two reasons:
1. 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 HAZARDOUS MATERIALS DISCLOSURE
sale(Sec.7044,Business&Professions Code) I have read the hazardous materials requirements under Chapter 6.95 of the
2. I,as owner of the property,am exclusively contracting with licensed contractors to California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
construct the project(Sec.7044,Business&Professions Code). compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should I store or handle hazardous material.
I hereby affirm under penalty of perjury one of the following three declarations: Additionally,should I use equipment or devices which emit hazardous air
1. I have and will maintain a Certificate of Consent to self-insure for Worker's contaminants as defined Bay Area Air Quality Management District I will
Compensation,as provided for by Section 3700 of the Labor Code,for the maintain co lance t upertino Municipal Code,Chapter 9.12 and the
Heal(.4 Sa ty Co a echo 25505,25533,and 25534.
performance of the work for which this permit is issued.
2. I have and will maintain Worker's Compensation Insurance,as provided for by Own r a or' gent• I I I (�
Section 3700 of the Labor Code,for the performance of the work for which this Date: 1 �J
permit is issued.
3. I certify that in the perfonnance of the work for which this permit is issued,I shall CONSTRUCTION LENDING AGENCY
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 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.)
become subject to the Worker's Compensation provisions of the Labor Code,I Lender's Name
must forthwith comply with such provisions or this permit shall be deemed
revoked. Lender's Address
APPLICANT CERTIFICATION ARCHITECT'S DECLARATION
I certify that I have read this application and state that the above information is I understand my plans shall be used as public records.
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 Licensed Professional
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
-ting of this permit.Additionally,the applicant understands and will comply with
)n-point source regulations per the Cupertino Municipal Code,Section 9.18.
Signature Date
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/ SUBC NTRACTOR LIST
JOB ADDRESS: PERMIT# l7
OWNER'S NAME: PHONE# /
GENERAL CONTRACT- BUSINESS LI ENS #
ADDRESS: CITY/ZIPCODE:
*Our municipal code requird all businesses working in ttk city to have a City of Cuper ino 6usinesA license
NO BUILDING FINAL OR FINA OCCUPANCY S ION(S) WILL BE SCHEDULE UN IL THE
GENERAL CONTRACTOR AND LL CON T HAVE OBTAINED A CITY C ERTINO
BUSINESS LICENSE. f /
I am not using any subcontractors:
Signature D to
Please check applicable subcontractors and complete the following information:
G/ 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
Ti e
I ( 1 �
Owner ont c or Signature Date
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: suew
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32617043 . 00
DATE ISSUED. . . . . . . : 11/17/2010
RECEIPT #. . . . . . . . . : BS000012035
REFERENCE ID # . . . : 10110116
SITE ADDRESS . . . . . : 22240 VARIAN WAY
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . . SHANKAR
ADDRESS . . . . . . . . . . : 22240 VARIAN WAY
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-1065
RECEIVED FROM . . . . : ATLAS TRILLO
CONTRACTOR . . . . . . . : TRILLO, STEVE LIC # 4269
COMPANY . . . . . . . . . . : ATLAS-TRILLO HVAC
ADDRESS . . . . . . . . . . : 1965 KYLE PARK CT
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408) 286-8931
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 3, 500 .00 1. 00 0 . 00 1.00 0. 00
1BSEISMICR VALUATION 3, 500 .00 0 .50 0 .00 0 .50 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
1TRAVDOC FLAT RATE 1. 00 42. 00 0 . 00 42 .00 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT 211.50 0 .00 211 .50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 211. 50 2440
---------------
TOTAL RECEIPT 211. 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
1
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 22240 varian way DATE: 11/17/2010 REVIEWED BY: building
APN: BP#: *VALUATION: 1$3,500
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or DuplexI-0 _ti; PENTAMATION FURN/AC
USE: PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $126
TOTALS: $126.00
Mech.Plan Check0.0 hrs $0.00
Mech.Permit Fee: IMPERMIT
-- LiOther Mech.Insp. 0.0 hrs L $42.00 D �, 1>a; 1 '�t � ��rtr�>s 1'/c� _I�t3��. Li
P!iimb. It 7p, 1. °_ l,iez-Imp. Pco
NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addh 7 info,
FEE ITEMS (Fee Resolution 09-051 Eff. T'1,10) FEE QTY/FEE MISC ITEMS
1,1ul1 C'Irec: l"ce:
St ppl. PC'1 Ce
PME Plan Check: $0.00
Su11l�1. Irtst� 1�'�e
PME Unit Fee: $126.00
PME Permit Fee: $42.00
{,on.�1i71Ction 1 I
;couslr'cal !e('11011'
Work Without Permit? 0 Yes No $0.00
Planrnn"Fc('s:
Travel Documentation Fee: ITRAVDOC $42.00 A
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bld)z Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 1 $211.50 $0.00 TOTAL FEE: $211.50
Revised: 11/08/2010
CITY OF
CITY OF CUPERTINO /0 00 /1is
FURNACE/AC
CUPERTINO PERMIT APPLICATION FORM
APN # S Date: '� �� /
a & 9 013 1L1
Building Address: VA-9-1
91 n f + ,�a!!�1 -
Owner's Name: f � � �� Phone#:
Contractor: /VTUV5 7� LLv Ae-A-
h G Phone #: R LIQ/ 93I
'
65 1� (rt�ie /-�1�K C� T- :51� Fax #: �f J J'� :
Contractor Licen #: f 1 / ryI Cupertino Business License#:
Contact: �� '-/a � Phone #: (nAo )��Fax#: 73 !,l 1
Building Permit Info:
lxs
Elect Plumb Mech
Residential Comme cial
Job Description: l k �xj�-�' IST/ V� FakKfki�
_ � 11
For kesidential Installations: I '161D
Attic F-1 1St 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: _ Type of Construction (Usage Class):
Strapped ❑ y On PlatformBonded New Location ❑ Replacement
Project Size: Ex ress ❑ Standard ❑ Lar e ❑ 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. <6/�-
Revised 01/07/09