12020088 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21447 KRZICH PL [CONDITIONING
NTRACTOR:,kAA FURNACE&AIR PERMIT NO: 12020088
OWNER'S NAME: HU ST1A-ISDN F AND HELEN Y2 STONE AVE DATE ISSUED:02/21/2012
ONE NO:(408)293-471 7
OWNER'S PHONE: 4086857116
SAN JOSE,CA 95125 PH
❑ 1:ICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ' ELECT PLUMB '
License CI
<iss MECH'1. RESIDENTIAL COMMERCIAL
Contractor M!!� �C\jAA)qC`E Date
JOB DESCRIPTION:REPLACE AND INSTALL TANKLESS WATER HEATER
I hereby affirm that I am licensed under the provisions of Chapter 9
(cornmencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm tinder 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.Ft Floor Area: Valuation:$1699
1 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 VPN Number:36205040.00 Occupancy Type:
permit is issued.
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 WITHIN 1$0 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We)agree to save
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 pertnit. Additionally,the applicant understands and will comply —_ Date: 6 �"
with all non-point. uce regit e Cupertino Municipal Code,Section Issued b},
9.18.
Signature
Date
RE-ROOFS:
❑ ONVNER-BUILDER DECLARATION All roofs shall be inspected prior to any rooting material being installed.If a roof is
installed without first obtaining an inspection,I agree to rernove 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: Date:
1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the prgiect(Sec.7044,Business&Protessions Code).
HAZARDOUS MATERIALS DISCLOSLIRE
hereby affirm tinder penalty of perjury one of the following three
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
1 have andwill maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Codence,Sect on 25532E)should I th the Cupertino sto a or handlal Code, e hazardous oter 9.12 matethe riIt &
material.
performance of the work for which this permit is issued.
Additionally,should I use equipment or devices which emit hazardous air
I have and will maintain Worker's Compensation Insurance,as provided for by
contaminants as defined by the Bay Area Air Quality Management District[will
Section 3700 of the Labor Code,for the performance of the work for which this maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
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 Own or authorized -
Date: -
Compensation laws of California. If,after making this certificate of exemption,I ` —
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this pen-nit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that l have read this application and state that the above information is Lender's Nam
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
indemnity and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may,accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I understand iffy plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
Licensed Professional
9.18.
Signature
Date
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino,CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
CUPERTINO
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: <<--
� PERMIT#
OWNER'S NAME: j V 14 S'/) PHONE#
GENERAL CONTRACTOR: L?t )4L-e-- BUSINESS LICENSE#
ADDRESS: ) ( Z , 4 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)TORS HAVE OBTAINED AHCITY OF CUPERTINO
GENERAL CONTRACTOR AND UNTIL THE
Ttors
BCONT C
BUSINESS LICENSE. -- -
�
I am not using any subcontractors: Signatu Date
Please check applicable subcontrnd 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
Date
Owner/Contr c or Signature
CITY OF CUPERTINO
6 ITEMS OF 12 PERMIT RECEIPT OPERATOR: patg
COPY #
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . 36205040 . 00
DATE ISSUED. . . . . . . : 02/21/2012
RECEIPT #. . . . . . . . . BS000016067
REFERENCE ID # . . . 12020088
SITE ADDRESS . . . . . 21447 KRZICH PL
SUBDIVISION . . . . . . :
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : HO STIMSON F AND HELEN Y
ADDRESS . . . . . . . . . . : 21447 KRZICH PL
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4942
RECEIVED FROM . . . . : AAA FURNACE & AIR C
CONTRACTOR . . . . . . . RANDO, JIM LIC # 8050
COMPANY . . . . . . . . . . AAA FURNACE & AIR CONDITIONING
ADDRESS . . . . . . . . . . 1712 STONE AVE
CITY/STATE//ZIP . . . SAN JOSE, CA 95125
TELEPHONE . . . . . . . . (408) 293-4717
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
--------- ------------- ---------- ---------- ---------- ---------- ----------
1ADMIN HOURS 1 .00 41.00 0 .00 41.00 0 . 00
1BCBSC VALUATION 1, 699 .00 1.00 0 .00 1.00 0 .00
1BSEISMICR VALUATION 1, 699 .00 0 . 50 0 .00 0 .50 0 . 00
1PPERMITFE FLAT RATE 1 .00 44 . 00 0 . 00 44 .00 0 . 00
1PRWHEATR UNITS 1 .00 26 . 00 0 . 00 26 .00 0 .00
1TRAVDOC FLAT RATE 1 .00 44 .00 0 . 00 44 .00 ------0 .00
---------- ---------- ---------- ----
TOTAL PERMIT 156 .50 0 .00 156 .50 0 .00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -
518 WATER HEATER
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 21447 krzich pl.
DATE: 02/21/2012 REVIEWED BY:
lark APN: BP#:
VALUATION: $1,699 -�
PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY
T7�NTAMATION PRWHEATR
USE: SFD or Duplex RMIT TYPE:
WORK replace and install tankless water heater.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Heater 1 PRWHEATR 1 # $26
TOTALS: $26.00
Plumb.Plan Che&TO.01 hrs $0.00
PlumbEPermit ee: IPPERMIT
Other Plumb lnsp. hrs $44.00
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc:.). These Lees are based on the relimina in ormation available and are onl an estimate. Contact the De t Lor addn'l info.
FEE ITEMS ! sc.s.. _:,t=7 1 d '' 1 I1= FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
---T-=
PME Unit Fee: $26.00
PME Permit Fee: $44.00
Administrative Fee: I ADMIN $41.00
Work Without Permit? 0 Yes Q No $0.00 E=
Travel Documentation Fee: I TRA VDOC $44.00
-£ ; -ast ir> ;= :a: IBSEI,SAKCR $0.50 Select an Administrative Item
''._4--�'?�;t�;issjosiFee� 113CBSC $1.00
SUBTOTALS: $156.50 $0.00 TOTAL FEE: $156.50
Revised: 1/19/2012
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408)777-3228 • FAX(408)777-3333 •buildinj(Qcupegino.org
misc
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PROJECT IN WII DLAND PROJECT IN
USE OF SFD or Duplex ❑ Multi-Family AREA RBAN INYes ❑ es [I No
U 'T'ERFACE ❑ No FLOOD ZONE ClClSTRUCTURE: C3 Commercial URBAN
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DESCRIPTION OF WORK
W ,� -
TOTAL VALUATION:
By my signature below,I certify to a of the fo ng: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information Ifi"ave pro ided's rrect. I have read the Description of Work and verify it is accurate. I agree to compiv with all applicable local
ordinances and state laws rely' g to buildi g c traction. I authorize representatives of Cupertino to enter the abo a-id nt�ed property for inspection purposes.
Signature of ApplicandAgent Date:
SUPPLEMENTAL INFORMATION REQUIREDa
MEPMiscApp_2011.doc revised 03/16/11