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15060006 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7712 OROGRANDE PL CONTRACTOR:LORD&SONS HEATING PERMIT NO: 15060006 AND AIR OWNER'S NAME: KARIM DARIUS AND PUTRI CINDYANI N E 13660 LLAGAS AVE DATE ISSUED:06/01/2015 SAN OWNER'S PHONE: 5105522394 MARTIN,CA 95046 PHONE NO:(831)274-6624 JOB DESCRIPTION:RESIDENTIAL COMMERCIAL LICENSED CONTRACTOR'S DECLARATION REPLACE(E)FURNACE&(E)A/C IN SAME LOCATIONS License Class _t Lie.# Contractor l �(` # S Date — /S! 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. hereby affirm under penalty of perjury one of the following two declarations: ldhave 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:$4400 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:36218031 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 WITFIIN 180 DAYS PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter ED INSPECTION. upon the above mentioned property for inspection purposes. (We)agree to save 180 D O indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the Issued Date: S granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 918. \ RE-ROOFS: SignatuQeaj�J Q � 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. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,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) I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I 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 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 upertino icipal Code,Chapter 9.12 and 1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,S tions 25505,25 3, nd 25534. ,^^^�� Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized age t: CJ! tf Date:CJ permit is issued. 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 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,I 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 is 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 upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, 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,Section Licensed Professional 918. Signature Date GENERAL PERMIT APPLICATION M E P"' COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 SCUP ER-C[[VO (408)777-3228• FAX(408)777-3333• building EDcupertino.org ` ❑PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS C APN tt P O OWN'ERNAME Ct � HONE E-MAIL ' �J�UP STREET ADD 7 STATE,ZI i ' FAX CONTACT NAME q-- PHOT E E-MAIL _I U '-� z lr i _z Nus/ 3k6 � 012v��ns vac u� � STREET ADDRESS CITY,STn�ATE,ZIP FAX � C—c_ S�I99)� ❑ owNER ❑ OWN'ER-BunDER ❑ OWNERAGE.NT 12 CONTRACTOR ❑CONTRACTORAGEN*I' ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBS LICENSE TYPE BUS.LIC C_ �C� COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP P ONE. ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC n COMPANY NAME E-MAU, FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ElSFD or DUPLEX ❑ MULTI-FAI,fILY PROJECT IN WILDLAND ElYES PROJECT IDI E3 YES IS THE BLDG AN El YES BUILDAG: r-1COMMERCIALURBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO DESCRIPTION OF WORK TOTAL VALUATION: By my signature below,I certify to each of the following: I am the property owner or authorized agent act oe e alf. I have read this` application and the information I have provided is correct. I have read the Description of Work and v tura L' agree to comply with all applicable local ordinances and state laws rel g to riding cotlstru on. uthorize representatives of Cupertino to enter theb ve/- end d property for inspection purposes. Signature ofApplicant/Agen. s ( U \C�� Date: (� — SUPPLEMENTAL INFORMATION REQUIRED <l -- �� M �� k'r� OVE HE COU�TEI2c � ,�y; r W �s RE -XEPMiscApp_2011.do0 revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 7712 OROGRANDE PL DATE: 06/01/2016 REVIEWED BY: MELISSA APN: 362 18 031 BP#: "VALUATION: $4,400 PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY PENTAMATION FURN/AC USE: SFD or Duplex PERMIT TYPE: WORK REPLACE E FURNACE & E A/C IN SAME LOCATIONS SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES A/C Units (<=1OK cfm) 1BREMAIR 1 # $72 Furnace, Forced-Air 1MFR=<100 1 # $143 TOTALS: $215.00 qIMPERHIT Mech.Plan Check 0.0 Phunh. Plan jImpE Elec.flan Chcck Mech.Permit Rea Permit Fee: Other Mech.Insp. 0.0ollw•Ph mh Usher Flee.Insla. LJ L tfi>ch.Insa�. F'sc: 1'laerrth. Ins11. Eslec.Inst, Fee: NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These fees are based on the prelimina in ormation available and are only an estimate. Contact the De t or addn'l info. FEE ITEMS (Fee Resolution 11-053 Ef. 7/1/13) FEE QTY/FEE MISC ITEMS Plan Cheek h'ee: Stippl. PC Fee PME Plan Check: $0.00 Permit Fee: .Szgyd. Insp P'ee PM E Unit Fee: $215.00 PNM Permit Fee: $48.00 Construction fax: Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes (E) No $0.00 Advanced P arming lees: Travel Documentation Fee: ITRAVDOC $48.00 i Strong Motion Fee: IBSEISMICR $0.57 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 R sUBTOTaLs" $357.57 $0.00 TOTAi FEE.• $357.57 Revised: 05/07/2015