10100006 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11500 CHARSAN LN CONTRACTOR:AAA FURNACE&AIR EDATE
T NO: 10100006
CONDITIONING
"'WNER'S NAME: MARISSA KOBYLENSKI 1712 STONE AVE ISSUED: 10/01/2010
.IWNER'S PHONE: 4082530237 SAN JOSE,CA 95125 NO:(408)293-4717
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL U COMMERCIAL
License ClassC C Zo Lic.# -7 4'irc 7 I REMOVE AND REPLACE EXISTING FURNACE AND
CONDENSER
ContractorDate tlU V HOOKUP 220
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 Valuation:$7900
performance of the work for which this permit is issued. Sq.Ft Floor Area:
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 th APN Number:36210043.00 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 relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgment:,
costs,yexpensmay accrue against said City in consequence of the Issued bDate•grantindditionally,the applicant understands and will complywith aegulations per the Cupertino Municipal Code,Sectior
9.18. RE-ROOFS:
gnatDate 69 _ 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.
❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for o le 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 compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044.
Business&Professions Code) HAZARDOUS MATERIALS DISCLOSURE
I,as owner of the property,am exclusively contracting with licensed contractor;to
construct the project(Sec.7044,Business&Professions Code). 1 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(a)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 equi ment 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 r r Quality Management District I
performance of the work for which this permit is issued. will maintain compliance wia Cu rt' unicipal Code,Chapter 9.12 and
the Health&Safety Code, ec io 2 0 533,and 25534.
I have and will maintain Worker's Compensation Insurance,as provided for b}
Section 3700 of the Labor Code,for the performance of the work for which thi i Owner or authorized agent: Date:
permit is issued.
I certify that in the performance of the work for which this permit is issued,I s call
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,I
become subject to the Worker's Compensation provisions of the Labor Code, must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions 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 I have read this application and state that the above information i;
correct.I agree to comply with all city and county ordinances and state laws r lating
to building construction,and hereby authorize representatives of this city to et ter
)n the above mentioned property for inspection purposes.(We)agree to sai a ARCHITECT'S DECLARATION
.emnify and keep harmless the City of Cupertino against liabilities,judgme its,
costs,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 comply
with all non-point source regulations per the Cupertino Municipal Code,Secv on Licensed Professional
9.18.
Signature Date
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
CUPERTINO Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS: l �j a G�A rSd N LN PERMIT# J
OWNER'S NAME: rngr-N S O b �►�.Sl�=� PHONE# M - 253 - 67372
GENERAL CONTRACTOR: HpQ� ✓f}-� /N C- BUSINESS LICENSE #
ADDRESS: Z S4 14tJi� Sor►� S� C'C CITY/ZIPCODE:S J 95''/2--�
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANURACTORS
INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR ANDA 2Z- Date
HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. l C
I am not using any subcontractors:
Signa e
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
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/C ractor Signature Date
CITY OF CUPERTINO
6 ITEMS OF 29 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN 36210043 . 00
DATE ISSUED. . . . . . . : 10/01/2010
RECEIPT #. . . . . . . . . BS000011611
REFERENCE ID # . . . : 10100006
SITE ADDRESS 11500 CHARSAN LN
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER DARISSA KOBYLENSKI
ADDRESS 1.1500 CHARSON LN
CITY/STATE/ZIP C:UPERTINO, CA 95014-4974
RECEIVED FROM . . . . : IiAA FURNACE
CONTRACTOR ]LANDO, JIM LIC # 8050
COMPANY jLkA FURNACE & AIR CONDITIONING
ADDRESS :_712 STONE AVE
CITY/STATE/ZIP . . . : ,),,AN JOSE, CA 95125
TELEPHONE (408) 293-4717
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- -------------
----------
---------- ----------
1BCBSC VALUATION 7, 900 .00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 7, 900 .00 0 . 80 0 . 00 0 . 80 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 . 80 0 .00 274 . 80 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
__ _ -------- ----------------------------
-- ---------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: I DATE: REVIEWED BY:
APN: BP#: *VALUATION: 1$7,900
;*PERMIT TYPE: Mechanical Permit P SAN CHECK TYPE: Alteration /Addition / Repair
___[PENTAMATION
PRIMARY SFD or Duplex �' FURN/AC
USE: p 1'1 Oil' I1"1:;{: 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 Check 0.0 hrs $0.00
Mech.Permit Fee: IMPERMIT ' rrntr, f'rt-rna Fcc. 1; f'z,-t,,;_F c'.'
Other Mech.Insp. 0.0 hrs $42.00 C)u; r I' ��i, ' %� .r� 7P6`1 .>t_Irrw_
Pifrrtth Ii,.i�; 1 l;tCc'_ U' 1' 'L'
NOTE. Theseees are based on the preliminary in ormation available and are only an estimate. Contact the Dept for addn'1 info,
FEE ITEMS (Fee Resolution 09-051 Eff ''UIO) FEE QTY/FEE MISC ITEMS
Ilan Che(
suppl. PC[cc,
c,
PME Plan Check: $0.00
1'c:'t'fnit fee:
Sappl. Irtsp Fec,
PME Unit Fee: $189.00
PME Permit Fee: $42.00
7',LV
r�i'(IId`.jtt;tiff /C c't'/c'14Ptt',
Work Without Permit? 0 Yes 0 No $0.00
1'lczrrttitT�r f'f� ',�:
Travel Documentation Fee: 1 TRA VDOC $42.00 i
Strong;Motion Fee: $0.79 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: t_ ,;274.79r_$0.00 TOTAL FEE: $274.79
Revised: 9/29/2010
CITY OF CUPERTINO
`
FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
t b CiAgr-.saV\ _Gr"_ .
Owner's Name: Phone #:
►'YLG r,s 5 J C a y ) e✓�S 1c 410�- -.25 3 2, 3 7
Contractor: r�G r\,C(p V f v t M91� )52t l rh34 e-g- Phone #: 3 -y / 7
_
Fax #: -6 7 -7
Contractor License #: `7 (0 Si 7 / Cupertino Business License #:
Contact: Dgr`a, -ta rv-� — q r y -'u w-z cr— Phone #: Llop _Zy,j (0 7
(J _ Fax #: oir - ZS 3 ' > -77
Building Permit Info:
i
Elect [�' Plumb [� _ Mech ❑�
Residential 2Commercial ❑
Job Description: ) errov.2 y, s+-iex5 F-Lirkzace 4-- Cord ensQ. //v 9A ki
P"t',*�a-C e 4- 6c1 -,�e,$ o v' I rJ 5 1 ( oCa--iD�,j - 1-10OLe-v� 2 Zo S,;;-,$ C/mac.
For Residential Installations:
Attic ❑ 1" loor 2nd floor ❑
Adhere to minimum setback requirement D�
For Commercial Installations:
Replacement same weight ❑ ,Additional weight (structural cales) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project:A -7 900 .D-d T}pe of Construction (Usage Class):
VAS
Strapped El On Platform Bonded New Location Replacement [�
Project Size: Express ❑ Standard ❑ Lard❑ Major ❑
Valuation:
J;
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 01/07/09