15090142 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 878 FERNGROVE DR CONTRACTOR:CALIFORNIA DELTA PERMIT NO: 15090142
MECHANICAL INC
OWNER'S NAME: ARUN KANNANy- 4 f4 A" 'H/( 6056 E BASELINE RD STE 155 DATE ISSUED:09/22/2015
OWNER'S PHONE: 4086010219 MESA,AZ 85206 PHONE NO:(866)692-5273
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
(N)MINI SPLIT UNIT IN LIVING ROOMNAMILY ROOM,
License Class C 2 0 Lie.# � 7 (N)A/C UNIT IN REAR YARD,AND(N)DEDICATED
1 // n / CIRCUIT
Contractor all& �C Crit?-1,'C-hDate 7 -2 2 % f
G'
1 hereby affirm that 1 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: Sq.Ft Floor Area: Valuation:$7500
t. 1 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
erformance of the work for which this permit is issued. APN Number:37538035.00 Occupancy Type:
WI-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 is issued. PERMIT EXPIRES IF WORK IS NOT STARTED
APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1 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 180 DAYS FROM LAST CALLED INSPECTION.
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to saveZ Z
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Issued b Date:
.
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, he applicant understands and will comply with
all non-point source regul a=perti'noMun' ial Coddee,Sectiioon 9.18. RE-ROOFS:
Signature 7 C �� 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:
1 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 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 HAZARDOUS MATERIALS DISCLOSURE
sale(Sec.7044,Business&Professions Code)
2. 1,as owner of the property,am exclusively contracting with licensed contractors to I have read the hazardous materials requirements under Chapter 6.95 of the
construct the project(Sec.7044,Business&Professions Code). California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I hereby affirm under penalty of perjury one of the following three declarations: Safety Code,Section 25532(x)should 1 store or handle hazardous material.
t. 1 have and will maintain a Certificate of Consent to self-insure for Worker's Additionally,should I use equipment or devices which emit hazardous air
Compensation,as provided for by Section 3700 of the Labor Code,for the 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
performance of the work for which this permit is issued. Health&Safety ,Sections 25505,25533,and 25534.
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 thisO e d agent: L�—2 2 fr•
permit is issued. Date:
3. 1 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 I hereby affirm that there is a construction lending agency for the performance of work's
become subject to the Worker's Compensation provisions of the Labor Code,I for which this permit is issued(Sec.3097,Civ C.)
must forthwith comply with such provisions or this permit shall be deemed Lender's Name
revoked.
Lender's Address
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is ARCHITECT'S DECLARATION
correct.I agree to comply with all city and county ordinances and state laws relating I understand my plans shall be used as public records.
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Licensed Professional
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
all non-point source regulations per the Cupertino Municipal Code,Section 9.18.
Signature Date
GENERAL PERMIT APPLICATION MEP
'• COMMUNITY DE'dELOPMENT DEPARTMENT•BUILDING DIVISION
hS
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
Im m Is C
(408)777-3228• FAX(408)777-3333• buildincCC CUDertino.org
CUP ERTIND n f1
I Jo"1 L9f
❑PLLNSING 1.'ECIi.A?\'ICAJL ELECTRICAL ❑hriSCELLANtOUS
PROJECT A3-'F-ESS 22 4:52cz vc APN r '275 '
OP✓NER NAMEE-1✓ie 1L
STREFTPDDRES° CITY 57?.TE ZIP F?J
CONTACT NAME
STREET? RESS CITY,STATE, ZIP F.AX
O i� � � J o
❑ 01ANZrER ❑ Ow1.ER-BUnZER ❑ OV NERAGENT ❑ CO\'MA.CTOR ❑C0171RACTORAGENT ❑ ARCH=I CT ❑ENGAEER ❑ DEITLOPER ❑ TI—NAN-1
CON`'P.4CT0 :�J•� LICENSE'UMBER LICEnS1 z= 40 BUS.LIC r
E-MAIL I FAX
C d
STRE DDR SS CITY,STATE,ZIP P
•� 2 U O
FIZCHITCTIENGINEER NAA.E LICENSE N'U]IBER BUS.LIC
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FATOI.Y I PROTECT LN w>1DLAND ❑ YES PROTECT IN ❑ YES IS THE BLDG AN ❑ YES
BUIIDLNG: ❑COWIMCIAL URBAN NTERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICHLERHOMEI ❑ NO
DESCP3TION OF R'ORK tIC 17
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� C
TOT.=.L V.tlL -.T'-,N; 7 O L2' O i RcCEI D b1
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on th property Owner's behalf. I have read this
application and the information I have provided is correct. I have read the Desch of'Work and verify it is . I agree to comply with all applicable local
ordinances and state laws relating tcy)luilding construction. I authorize re of Cupertin r the above-identified property for inspection purposes.
Sign,mature ofApplicaUAgent:-OW—_ Date:
SUPPLEMENTAL D\TFORMATION P QUIRED OFFICE L'SE ONLY
LJ OPER-TIM-COUNTER
EXPRESS
i
❑ LARGE
❑ ?�i=.JOR
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 878 FERNGROVE DATE: 09/22/2015 REVIEWED BY: PHUONG
APN: 375-38-035 BP#: "VALUATION: 1$7,500
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Repair
PRIMARY SFD or Duplex PENTAMATION FURN/A
USE: PERMIT TYPE:
WORK N MINI SPLIT UNIT IN LIVING ROOM/FAMILY ROOM N A/C UNIT IN REAR YARD AND N
SCOPE DEDICATED CIRCUIT
Mech. Plan Check I 0.0 hrs $0.00 Elec. Plan Check 0.0 hrs $0.00
Mech. Permit Fee: IMPERMIT Elec. Permit Fee: IEPERMI7'
Other Mech. Insp. 0.0 hrs $48.00 Other Elec. Insp. 0.0 1 hrs 1 $48.00
NOTE: This estimate does not include fees due to other Departments(i.e. Planning, Public Works,Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the reliminar) information available and are onl),an estimate. Contact the Dept for addn7 info,
FEE ITEMS Wee Resoluiion 11-053 Ejl: 7%1113/ FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 1 # Mechanical
Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $72.00 IBREMAIR A/C Units(<=10K cf n)
PME Plan Check: $0.00 1 Electrical
Permit Fee: $0.00 $143.00 1 IBREMMISC Special Circuits
Suppl. Insp. Fee:Q Reg. Q OT 0.0 hrs $0.00 0 # Mechanical
PME Unit Fee: $0.00 $72.00 IBAPPLOT Other Appliance/Equip
PME Permit Fee: $96.00
Administrative Fee: (ADMIN $45.00 O
Work Without Permit? O Yes (E) No $0.00 E)
Advanced Planning Fee: $0.00 Select a Non-Residential E)
Travel Documentation Fee: ITRA VDOC $48.00 Building or Structure
Strong Motion Fee: IBSEISMICR $0.98 Select an Administrative Item
BldgStds Commission Fee: IBCBSC $1.001 1
SUBTOTALS: $190.981 $287.00 TOTAL FEE: $477.98
Revised: 07/02/2015
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