10110119 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19761 BIXBY DR CONTRACTOR:SANDIUM PERMIT NO: 10 110 119
OWNER'S NAME: BORIS AND YERMAKOV ABRAMZON 4223 VERDIGRIS CIR DATE ISSUED: 11/18/2010
OWNER'S PHONE: 4083555234 SAN JOSE,CA 95134 PHONE NO:(408)894-9072
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
Q REPLACE RESIDENTIAL FURNACE.
License Class Z'>0 L l Lic.# C- Zo
Contractor C{�Jw Date 2'(O
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.
Sq.Ft Floor Area: Valuation:$4300
1 hereby affirm under penalty of perjury one of the following two declarations:
1. I have and will maintain a certificate of consent to self-insure for Worker's APN Number:36909050.00 Occupancy Type:
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
2. 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 PERMIT EXPIRES IF WORK IS NOT STARTED
permit is issued. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
APPLICANT CERTIFICATION 180 DAYS FROM LAST CALLED INSPECTION.
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 Issued by. Date:
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
granting of this permit. Additionally,the applicant understands and will comply with RE-ROOFS:
all non-point source-fggulations per the Cupertino Municipal Code,Section 9.18. All roofs shall be inspected prior to any roofing material being installed.If a roof is
�7 installed without first obtaining an inspection,I agree to remove all new materials for
t
Signature. ��_�� / Date (� �� inspection.
Signature of Applicant: Date:
r' OWNER-BUILDER DECLARATION
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1..,..eby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1. I,as owner of the property,or my employees with wages as their sole HAZARDOUS MATERIALS DISCLOSURE
compensation,will do the work,and the structure is not intended or offered for I have read the hazardous materials requirements under Chapter 6.95 of the
sale(Sec.7044,Business&Professions Code) California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
2. 1,as owner of the property,am exclusively contracting with licensed contractors to compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
construct the project(Sec.7044,Business&Professions Code). Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
I hereby affirm under penalty of perjury one of the following three declarations: contaminants as defined by the Bay Area Air Quality Management District I will
1. I have and will maintain a Certificate of Consent to self-insure for Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation,as provided for by Section 3700 of the Labor Code,for the Health&Safety Code,Sections 25505,25533,and 25534.
performance of the work for which this permit is issued. Ow o�hori,,d gent
2. I have and will maintain Worker's Compensation Insurance,as provided for by �.(r Date:
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. CONSTRUCTION LENDING AGENCY
3. 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 I hereby affirm that there is a construction lending agency for the performance of work's
Compensation laws of California. If,after making this certificate of exemption,I 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 Lender's Address
revoked.
ARCHITECT'S DECLARATION
APPLICANT CERTIFICATION I understand my plans shall be used as public records.
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 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
ng of this permit.Additionally,the applicant understands and will comply with
i-point source regulations per the Cupertino Municipal Code,Section 9.18.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 19761 bixby4ff DATE: 11/18/2010 REVIEWED BY: building
APN: BP#: /0& 2 *VALUATION: 1$4,300
xPERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY 7t?7.11, PENTAMATION FURN/AC
USE: SFD or Duplex j /OW>,rl! PERMIT TYPE:
WORK residential furnace replacement
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $126
TOTALS: $126.00
Mech.Plan Check 0.0 hrs $0.00 _ 1; 1'z,ttt t'dr c,{
Mech.Permit Fee: IMPERMIT P,
I I
Other Mech.Insp. 0.0 hrs $42.00 Li
NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'1 info,
FEE ITEMS (1%ee Resohitiorr 09-051 Eff 7,'1,10) FEE QTY/FEE MISC ITEMS
P/on C h((1;A /"u""
.flip }l. PC
PME Plan Check: $0.00
Pyr-tnit Fcc-
PME Unit Fee: $126.00
PME Permit Fee: $42.00
Ccjivarrrc•ruon 7'ax
It:ut.sfLi;rat I?t'tvotti
Work Without Permit? 0 Yes (F) No $0.00
Travel Documentation Fee: ITRA VDOC $42.00
Strong Motion I'ee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS:" $211.50 $0.00 TOTAL FEE: $211.50
Revised: 11/08/2010
CITY OF CUPERTINO
5 ITEMS OF 11 PERMIT RECEIPT OPERATOR: suew
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36909050. 00
DATE ISSUED. . . . . . . : 11/18/2010
RECEIPT #. . . . . . . . . : BS000012039
REFERENCE ID # . . . : 10110119
SITE ADDRESS . . . . . : 19761 BIXBY DR
SUBDIVISION . . . . . . :
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . . :
OWNER . . . . . . . . . . . . : BORIS AND YERMAKOV ABRAMZON
ADDRESS . . . . . . . . . . : 19761 BIXBY DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : YIU-HANG LEE
CONTRACTOR . . . . . . . : MICHAEL LEE LIC # 28867
COMPANY . . . . . . . . . . . SANDIUM
ADDRESS . . . . . . . . . . : 4223 VERDIGRIS CIR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95134
TELEPHONE . . . . . . . . : (408) 894-9072
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 4, 300 .00 1. 00 0 .00 1 . 00 0 . 00
1BSEISMICR VALUATION 4, 300 .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
----------------- --------------- --------------------
CREDIT CARD 486.39 VISA
---------------
TOTAL RECEIPT 486.39
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 1 N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: -76 ;X� PERMIT#
OWNER'S NAME: ��5 PHONE# -A SSS S L3
GENERAL CONTRACTOR: �1c,,,� BUSINESS LICENSE#
ADDRESS: CITY/ZIPCODE: SJ S13
*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.
I am not using any subcontractors: / ''
Signature Date
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 -F
Owner/Contractor Signature Date
acloF
CITY OF CUPERTINO
FURNACE/AC
CUkINO PERNUT APPLICATION FORM
APN# u ` � Q �^ Date: � � ��1211
�
9'
Building Address: JU
Owner's Name:
l Phone#: -off
� - ��a L� �
Contractor: Phone#: 43 6qo D Z>Y
Fax#: �So 44
Contractor License#: Cupertino Business License#:
Lys
Contact: Phone#:
Fax #:
Building Permit Info:
Elect ❑ Plumb ❑ Mech
Residential Commercial ❑
Job Description:
For Residential Installations: 1
Attic ❑ 1"floor Er-, 2nd 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):
r � _
Strapped 0 On Platform Bonded New Location Replacement ❑�
Project Size: Express M tandard ❑ Large ❑ Major❑
Valuation: 4 4W
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