11120020 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20556 MC CLELLAN RD CONTRACTOR:JON R CRASE PERMIT NO: 11120020
CONSTRUCTION INC
OWNER'S NAME: BERNARD LEO J AND GERMAINE B T 164 GILMAN AVE STE A DATE ISSUED: 12/022011
R'S PHONE: 4082523958 CAMPBELL,CA 95008 PHONE NO:(408)370-1495
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r-1r,PLUMB
License Class U Lic.N 6115- /T/
p � !� MECH r r
RESIDENTIAL COMMERCIAL r
Contractor Catse &A/ Datebi A- //
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE FLOOR FURNACE&INSTALL WALL FURNACE
(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:
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. Sq.FI Floor Area: Valuation:$2500
1 have and will maintain Worker's Compensation Insurance,m provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. APN Number:35918059.00 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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply
9 'Date:
Signature ! Date
RE-ROOFS:
sp OWNER-BUILDER DECLARATION 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
I hereby affirm that I am exempt from the Contractor's License Law for One of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages m their sole compensation, Signature of Applicant: Date:
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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 2.5534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District 1 will
permit is issued. 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,l 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 Owner or h ized agent:
Compensation laws of California. If,after making this certificate ofexemption,l Date: /d A !/
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
1 h reb affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for tch this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
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 Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
i nify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
d expenses which may accrue against said City in consequence of the
mof this permit.Additionally,the applicant understands and will comply. I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
• CITY OF CUPERTINO '
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35918059. 00
DATE ISSUED. . . . . . . : 12/02/2011
RECEIPT #. . . . . . . . . : BS000015474
REFERENCE ID # . . . : 11120020
SITE ADDRESS . . . . . : 20556 MC CLELLAN RD
SUBDIVISION . . . . . . :
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . :
OWNER . . . . . . . . . . . . : BERNARD LEO J AND GERMAINE B T
ADDRESS . . . . . . . . . . : 20556 MCCLELLAN RD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-3004
RECEIVED FROM . . . . : JON R CRASE CONSTR
CONTRACTOR . . . . . . . : JON R CRASE LIC # 22250
COMPANY . . . . . . . . . . : JON R CRASE CONSTRUCTION INC
ADDRESS . . . . . . . . . . : 164 GILMAN AVE STE A
CITY/STATE/ZIP . . . : CAMPBELL, CA 95008
TELEPHONE . . . . . . . . : (408) 370-1485
• -FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS 1. 00 41.00 0. 00 41.00 0. 00
1BCBSC VALUATION 2, 500 .00 1.00 0. 00 1.00 0. 00
1BSEISMICR VALUATION 2, 500. 00 0.50 0.00 0.50 0. 00
1MFR=<100 UNITS 1. 00 130.00 0.00 130.00 0. 00
1MPERMITFE FLAT RATE 1. 00 44.00 0. 00 44 .00 0. 00
1TRAVDOC FLAT RATE 1.00 44 .00 0. 00 44 .00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 260.50 0.00 260.50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 260.50 #60807
---------------
TOTAL RECEIPT 260.50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
•
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 l^_
• CUPERTINO (408)777-3228• FAX(408)777-3333• buildinG(G,cuoertino.or0 M ' S V
LU ING MECHANICAL �(/J ELECTRICAL MISCETL.ANEOUS
PROJEC[ADDRFSS /�/-�p�`/ M� // P ley
. � VAI'
OWNER NAME Cf/G/\MUt/O✓� ' /� l- PHONE�/D� -d?S;-.39SS EMAE.
STREET ADDRESS dash Merle)%. Oa,, CITY STATE/,ffi FAX
M1 CUOC�vp/p p�OC//t �lSD/Y
CONTACT NAME Qyi�H✓ Q '/HQ 'OS/ E-MAIL
J'�C1n (O�lS7Y✓C�dn .t �r,�-
STREET ADDRESS ATE, ZIPFAX
/6 Y �JuN.a /7 vc /Tr eiv>�i°6c u to X,,- 3?0 oz 3T
9 Sao
❑ OWNER ❑ OWNER-GUIDER ❑ OWNER AGSM ❑ CONTRACTOR ❑CONTRACrt)RAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME ^ ^'C ,p�N LICENSE NUMBER///S_'/7 LI TYPE BUS,Lica
COMPANY NAME E-MAIL IO 7 7 FAX
E Gin/.
STREET ADDRESS/1,,/
b y (o/t l�J,v7✓ c"YG/,a iM�.sL u _ cis 9c17�8 q� 3 7 1 yYS—
ARCHII'ECT/ENGINEER NAME LICENSE NUMBER BUS.LIC p
COMPANY NAME E-MAB. FAX
STREET ADDRESS CITY.STATE.ZIP PHONE
SE OF pSft.DUPLEX ❑ MULTI-FAMILY PROIECT IN WILDL ND ❑ YES PROJECTIN ❑YES IETII:BLDOAN L3 YES
BUDDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE [3 NO EICHLER HOME? [I No
DESCRIPTION OF WORK
�1+�/ dvd( j=GODx rL.n/fKC- S J�✓S�L/w6 �..JiPu .�-rov.✓r
TOTAL VALUATION: aSvD RECEIVED BY:
By my signature below,I certify to each of the following: I are the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the informadon I have provided is comect 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 construe n uthorize representatives of Cupertino to enter the above-i ti d property fm inspection pu()oscs.
Signature GfApplicanVrn
Agt Date: /
SUPPLEMENTAL RMATION REQUIRED OFFICE USE ONLY
L7 OVER-THE-COUNTER
6
❑ EXPRESS
Y
U
_ ❑ STANDARD
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❑ LARGE
6
❑ MAJOR
MEPMucApp 2011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
• ADDRESS: 20556 Mcclellan rd. DATE: 12/0212011 REVIEWED BY: bobs.
APN: BP#: *VALUATION: $2,500
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD Or DUp18X PENTAMATION FURN/AC
USE: PERMIT TYPE:
WORK install wall furnace.
SCOPE
APPLIANCE/EQUIP TYPE FEE TD QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $130
TOTALS: $130.00
Mech.Plan Check 0.0 hrs $0.00 Numb, P/an Check Eler,f'(nrr Checi,"
Mech.Permit Fee: fMPERMIT P(unib. Ile,ntit Fee.: F_7r.. Perrin Pre:
• Other Mech. Insp. 1 0.0 hrs $44.00 Dthe, Ifiauh In.sp. Li nrher 6'fec. bap, El
ddnrh.fnep. Fee: Plwafi. Laip, tee: Eieh.fnap. Fee.
NOTE: This estimate does not include fees due to other Deparements(!e.Planning,Public Warks,Fire,Sanitary Sewer District,School
District etc . These fees are based on the preffidna in ormatlon available and are only an estimate. Contact the Dept foraddn7Into.
FEE ITEMS f1•"ee Resolution 11-053 E(f 7/1/!17 FEE QTY/FEE MISC ITEMS
Plan Check f ec:
5uppl. PCFee
PME Plan Check: $0.00
Permit Pce:
Suppl. hcsp Fee
PME Unit Fee: $130.00
PME Permit Fee: $44.00
Consaruaiun 74V
Administrative Fee: 1ADM1N $41.00
Work Without Permit? 0 Yes (F) No $0.00
Advanced Planning
Travel Documentation Fee: IMVDOC $44.00
Shone Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
• Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $260.50 $0.00 TOTAL FEE: $260.50
Revised: 10/01/2011
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
DU P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: OSSG M a C tcGG PERMIT#
OWNER'S NAME: 15E'xf/^� PHONE# 5eY-0S-Y?-
GENERALCONTRACTOR: - Cpn/. BUSINESS LICENSE#
ADDRESS: /4y CITY/ZIPCODE:
*Our municipal code requires all usinesses 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 a mplete 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
Owner/Contractor Signature Date