10080206 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21436 HOLLY OAK DR CONTRl,CTOR:ALI'S CONSTRUCTION& PERMIT NO: 10080206
REMOD SLING
"„►'NER'S NAME: BIN LI&EARL PENG 681 E BLOKAW RD DATE ISSUED:08/27/2010
. .vNER'S PHONE: 4084804699 SAN JO:'E,CA 95112 PHONE NO:(408)898-6474
❑ LICENSED CONTRACTOR'S DECLARATION r– [—
BUILD[NG PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# F r F
MECH RESIDENTIAL COMMERCIAL
Contractor ate
I herebyaffirm at I a ensed under the rovisi s o Chapter 9 JOB DESCRIPTION:REPLACE HEATER UNIT AT SAME LOCATION
(commencing with Se 7000)of Division 3 of the mess&Professions **SEE TOTES**
Code and that my 1' se 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:$2500
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. h7
APN Number:36202033.00 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, W[THIN 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-pointsource regulations per the Cupertino Municipal Code,Section
9.18. 1/ .. Issued't Date:
C;-nature Date L2- 0
❑ O R-BUILDER DECLARATION RE-ROOFS:
All roof, shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirmat 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: inspectic n.
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, Signatur-,of Applicant: Date:
Business&Professions Code)
1,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 r-ad the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the Califon iia 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 Additio sally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintai n 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,k 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 OwnerJhXr)
izedagent: C
become subject to the Worker's Compensation provisions of the Labor Code,I must GDate: 7 N
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LEN G AGENCY
APPLICANT CERTIFICATION I hereby aff rm at 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 fhi permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender s ame
to building construction,and hereby authorize representatives of this city to enter
-,n the above mentioned property for inspection purposes.(We)agree to save Lender s Address
;mnify and keep harmless the City of Cupertino against liabilities,judgments,
vests,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I unders tand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
a
R. CITY OF CUPERTINO
.. laic
FURNACIJ/AC
CUPEI�TINO PERMIT APPLICATION FORMnJ
2 Qxil
APN#
Date:
Building Address:�'�
Owner's Name: ► Phone#:
Contractor: Phone#: (40 $q 8 —'6 tq _
Fax #:
Contractor License#: 13 anq y3_� _ Cupertino Business License#:
��- . .
Contact: Phone#:
Fax #:
Building Permit Info:
Elect Plumb Mech
Residential M C z)mmercial
Job Description: .te
For Residential Installations:
Attic A 1St floor ❑ 2nd floor
Adhere to minimum setback requirement ❑
For Commercial Installations:
Replacement same weight ❑ Addi-ional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction(Usage Class):
2S-00 U(3 W4
Strapped On Platform JK Bonded New Location Replacement
Project Size: Express [Standard ❑ Large ❑ Major❑
Valuation:
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in Man set & the sheet index.
Revised 01/07/09
CITY OF CUP ERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: DY,TE: REVIEWED BY:
APN: BP#: "VALUATION: 1$2,500
*PERMIT TYPE: Mechanical Permit PLAN CHICK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex .�'' 1, PENTAMATION 1 RMAP6
USE: I,Ut�,:' ir�L:,�: PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY BP FEES
Furnace, Forced-Air 1MFR=<100 1 $126
TOTALS: $126 00
Mech.Plan Check 0.0 hrs $0.00 I'l;rmh. !'Icu,C;,•_�rl Llec:. P/;m Uh,(,k
Mech.Permit Fee: IMPERMIT ;'l;rmf l'c; ;; F!,;: l;kr I,1;r1t N I'ec
Other Mech.Insp. 0.0 hrs $42.00 >r!;��, T;,;.;, ;r;
1!.'ch
NOTE: Thesefees are based on the preliminary information availabl?and are only an estimate. Contact the De t or addn'1 info,
FEE ITEMS (Fee Resolution 09-051 Elf. 7//'10) FEE (?TY/FEE MISC ITEMS
1 ccin Circ'(,d: r cc
T71S11,F)/;l. P<"Fee
PME Plan Check: $0.00
SI/p/4. /,;.�p 1.cc
PME Unit Fee: $126.00
PME Permit Fee: $42.00
C oo, lrrwtionT-1
,'J"Oii,Nlk d/
Work Without Permit? O Yes E) No $0.00
Travel Documentation Fee: ITRA VDOC $42.00
i
Select an Administrative Item
Bldj4 Stds Commission Fee: IBCBSC $1.00
SUB ` $211.00 $0.00 TOTA FEE:;: $211.00
Revised: 8/17/2010
M.IndDDr Mr Quality and Finishes
1.USE ixaww!lilo-VOE Faird 1 1AM isalth pts y=yes 0
2.Use Low VOC,Water--Based tNood Finishes 2 IAOJI lealth pts y=yes D
3.Use Low7jo VOC Adhesives 3 IAOJ1 iealth pts yeses 0
4.Use Salvaged Materials for Interior Finishes 3 Rescurce pts yeses D
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 5IAQ/Iiealth pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 1AW iealth pts y--yes 0
7,�eal�l • 4QF _ _ 41AQ/7pts
es 0
B.Use FSC Certified Materials for Interior Finish 4 Resoyes D
9.Use Finger-Jointed or Recycled-Content Trim 1 Resoyes D
10.Install Whole House Vacuum System 3 IAQ. yes 0
N.Flooring
1.Select FSC Certified Wood Flooring B Resource pts y=yes 0
2.1Ssa Rapidfy►llenepral�{e F7oMug�Aateria�s 4 Resor irce pts y--yes D
3.Use Recycled Content Ceramic Tiles 4 ResoArce pts y=yes D
4.Install Natural Linoleum in Place of Vinyl 5 IAQA iealth pts y--yes 0
5.Use Exposed Concrete as Finished Floor 4 Resp lrce pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Reso irce pts y--yes 0
1 1 1
Total Points Available: 140 1301 57
0
Total Points Project Reeelved: ',
0
;3-"-Z7-to
r2:data/progsrgreenbuPcfni igLfiderinestramodelarsigreanpdintsMnal2.12.D4prDlectedyJs
CITY OF CUPERTINO
RECEIPT NUMBER: BS000011316
RECEIVED BY: PAT PAYOR: MEHRDAD A ZAMANI
TODAY'S DATE: 08/27/10 REGISTER DATE: 08/27/10
TIME: 15:23
8
1BCBSC 10080206 $1 .00
1MFR=<100 10080206 $252 .00
1MPERMITFE 10080206 $84 . 00
1TRAVDOC 10080206 $84 .00
1BCBSC 10080207 $2 .00
1BSEISMICR 10080207 $1.00
1WINREP 10080207 $760 .00
BUSINESS LICENSE TAX FANTSTIC BAY BUILDER $114 . 00
----------------
TOTAL DUE: $1,298 .00
CREDIT CARD: $1, 298 .00 REF NUM: VISA
TENDERED CHANGE
$1,298 . 00 $.00
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
S1 Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
PERMIT#
JOB ADDRESS: 2 0 Y ' '
OWNER'S NAME: PHONE#
GENERAL CONTRACTOR: LI Cp i/1�� BUSINESS LICENSE#
ADDRESS: CITY/ZIPCODE: S
*Our municipal code requires all businesses working in the cit,/to have a City of Cupert 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: Date
SignaturE
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 ff
Heating f0m u
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
r/Contractor Signature Date