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11030144 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10098 IMPERIAL AVE CONTRACTOR:A&H HEATING PERMIT NO: 11030144 OWNER'S NAME: HANH HO 770 CHESTNUT ST DATE ISSUED:03/30/2011 OWNER'S PHONE: 4088051401 SAN JOSE,CA 95110 PHONE NO:(408)279-0722 -41 � LICENSED CONTRACTOR'S DECLARATION � r nn y BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Ci`zD Lic.# �� L ,Ap MECH RESIDENTIAL COMMERCIAL Contractor r C: Date ' 3L I hereby affirm that I am licensed tinder the provisions of Chapter 9 JOB DESCRIPTION:INSTALL CENTRAL A/C TO PRPPED SYSTEM,ADHERE 40 (commencing with Section 7000)of Division 3 of the Business&Professions MINIMUM SET-BACK REQUIREMENTS 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. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$4200 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:35722010.00 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 to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Issued by: Date: S–`�' Signature Date '✓V r OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 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, Signature of Applicant: Date: Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air permit is issued. 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 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 Compensation laws of California. If,after making this certificate of exemption,I O ner or authorized become subject to the Worker's Compensation provisions of the Labor Code,I must R.te: forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities,judgments, co—,and expenses which may accrue against said City in consequence of the ng of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION H. all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional 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(c-cupertino.org MISC ❑PLUNIBING6 MECHANICAL LECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS / APN f1 7 OWNERNAME P �� //LQ• / E-MAIL STREET ADDRESS Ogg CITY. STATE,ZIP CONTACT NAME �/"• ""'� S PHONE Z?-iP72 Z E /tr`f ! /F •`�- 1 STREET ADDRESS �� n f QI ,T� CITY,STA ZIP � � ��l`O FAXW qWZ�Q /v ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGGENTy('�' ❑ ARCHITECT I❑ENGINEER ❑ DEVELOPER T❑TENANT CONTRACTOR NAME * r w LICENS O4� � LICENSE TYP Z � BUS.LIC# COMPANY NAME > "F-- a �j` E-MAIL `✓�� `'�'G!/ /WL• FAXZTJV� �Ol L STREET ADDRESS 776 (: ��T r C ,S ATE zj, 1004� D P ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑ SFD or Duplex Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ NO DESCRIPTION OF WORK /�� I �� `� RECEIVED BY TOTAL VALUATION: 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. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. I autho .ze representatives of Cupertino to enter the above-identifiedproperty for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQT-)U D U. � €��3,'fei�LFBAc1�1'11�,�..�a•-t_� - ;-t Pk- r SQ . MEPMiscApp_1011.doc revised 03/16/11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10098 imperial DATE: 03/30/2011 REVIEWED BY: bobs. APN: BP#: `°VALUATION: 1$4,200 "PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION FURN/AC USE: PERMIT TYPE: WORK install A/C unit to existing prepped system, adhere to min. set back requirements. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES A/C Units (<=10K cfm) 1BREMAIR 1 # $63 TOTALS: $63.00 Mech.Plan Check0.0 hrs $0.00I T Mech.Permit Fee: IMPERMIT Other Mech.Insp. 0.0 hrs $42.00 NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'l info. FEE ITEMS (I�e Resolution 09-051 Eff. 7/1,-'10) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $63.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes 0 No $0.00 Travel Documentation Fee: 1TRAVDOC $42.00 Stronjz Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $148.50 $0.00 TOTAL FEE.-] $148.50 Revised: 01/15/2011 CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35722010. 00 DATE ISSUED. . . . . . . : 03/30/2011 RECEIPT #. . . . . . . . . : BS000013037 REFERENCE ID # . . . : 11030144 SITE ADDRESS . . . . . : 10098 IMPERIAL AVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . : OWNER . . . . . . . . . . . . . HANH HO ADDRESS . . . . . . . . . . : 10098 IMPERIAL AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : DALE PHELPS CONTRACTOR . . . . . . . : PHELPS, DALE LIC # 12079 COMPANY . . . . . . . . . . : A & H HEATING ADDRESS . . . . . . . . . . : 770 CHESTNUT ST CITY/STATE/ZIP . . . : SAN JOSE, CA 95110 TELEPHONE . . . . . . . . : (408) 279-0722 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 4,200 . 00 1. 00 0. 00 1 .00 0 .00 1BREMAIRHA NO.UNITS 1 . 00 63 . 00 0. 00 63 . 00 0 . 00 1BSEISMICR VALUATION 4, 200 . 00 0 .50 0. 00 0 .50 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 148 .50 0. 00 148.50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 148 .50 VISA --------------- TOTAL RECEIPT 148 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL 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: 0C> 1 W M4?4`4—Z— PERMIT# OWNER'S NAME: *)W l-f tfo PHONE# GENERAL CONTRACTOR: #SK477BUSINESS LICENSE# ADDRESS: Z 7d w CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. r I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: V 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/Contractor Signature Date