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12020089 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10372 SCENIC CIR CONTRACTOR:AAA FURNACE&AIR PERMIT NO: 12020089 CONDITIONING OWNER'S NAME: ISBELL TIM D AND ROBERTA J 1712 STONE AVE DATE ISSUED:02/21/2012 OWNER'S PHONE: 408 3090941 SAN JOSE,CA 95125 PHONE NO:(408)293-4717 ❑ LICENSED rCONTRACTOR'S �iDECLAEZAT[ONBUILDING PERMIT INFO: BLDG } ELECT PLUMB License Class re.# MECH ' RESIDENTIAL COMMERCIAL Y� A ' Z Contractor 8a W t`l)� 4 Date JOB DESCRIPTION:REPLACE AND INSTALL NEW WATER HEATER 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. 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 tine performance of the work for which this permit is issued. Sq,Ft Floor Area: Valuation:$900 1 have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of tine Labor Code,for the performance of the work for which this .4PN Number:35707025.00 Occupancy Type: pernait 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 180 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 pernait. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Issued by. Date: Signature C ` Date �JZ RE-ROOFS: ❑ 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 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: I,as owner of the property,or nay employees with wages as 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) 1,as owner of the property,ani 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 ander penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of tine I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I 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& Safety performance of'the work for which this permit is issued. Safe Code,Section 25532(x)should I store oa•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 I will 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 Ow r or authorized _se.nt;_ _._..__ — `._10 Compensation laws of California. If,after making this certificate of exemption,I cN Dater! becorne subject to the Worker's Compensation provisions of the Labor Code,I must G , forthwith comply with such provisions or this permit 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 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 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 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 PERMIT RECEIPT OPERATOR: Patg 6 ITEMS OF 12 COPY # Sec : Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . 35707025.00 DATE ISSUED. . . . . . . 02/21/2012 RECEIPT #• • . . . . . . . . ESO00016067 REFERENCE ID # . . . 12020089 SITE ADDRESS . . . . . 10372 SCENIC CIR SUBDIVISION . . . . . . : CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . • OWNER . . . . . . . . . . . . : ISBELL TIM D AND ROBERTA J ADDRESS . . . . . . . . . . 10372 SCENIC CIR CITY/STATE/ZIP . . . CUPERTINO, CA 95014 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 . . . . . . . . : (408293-4717 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS-REC- NEW BAL- ---- --- - ---- --- ---------- ------ ------ ------1 .00 ----- -41-00 0 .00 41 .00 0 .00 1ADMIN HOURS 900 .00 1. 00 0 .00 1 .00 0 .00 1BCBSC VALUATION 0 . 50 0 .00 0 .50 0 .00 JBSEISMICR VALUATION 900 .00 1 .00 0 .00 44 .00 0 . 00 44 .00 JPPERMITFE FLAT RATE 26 . 00 0 .00 26 .00 0 .00 JPRWHEATR UNITS 1.00 0 . 00 44 .00 0 .00 1TRAVDOC FLAT RATE 1 .00 44 .00 --- ---------- ---------- ----156 . 50 0 .00 156 .50 0 .00 TOTAL PERMIT : METHOD OF PAYMENT AMOUNT REFERENCE NUMBER------- ---- ---------- --REFERENCE ---------- CHECK 313 .00 #39859 ----------- TOTAL RECEIPT : ---- 313 .00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION ------- ---------------------------- -------- ---------------- ----------- 518 WATER HEATER CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRE SS: 10372 scenic circle DATE: 02/21/2012 REVIEWED BY:VALU ATN: 1$900 BP#: APN: PLAN CHECK TYPE: Alteration Addition Repair PERMIT TYPE: Plumbing Permit DRWHEATR PRIMARY OF-D or Duplex PERMIT TYPE: USE: WORK re lace and install new water heater, SCOPE FEE ID QTY UNITS BP FEES APPLIANCE EQUIP TYPE — Water Heater IPRWHEATR 1 # $26 $2600 TOTALS: Plumb.Plan C hrs $0.00 lun.b.P,1a, Check Plumb.Permit Fee: ]PPERAWT 0.0 hrs $44.00 Other Plumb Insp. 94E Planning,Public FVorks,Fire,Sanitary rt District,School NOTE: This estimate does not include fees due to other Departments(i.e. n estintate. Contact the De-pt-for addn'l info. District,etc.). These-fees are based on the erelining ry inLo tion a ' ble and are o!�E a MISC ITEMS FEE ITEMS FEE QTY/FEE PME Plan Check: $0.00 PME Unit Fee: $26-00 PME Permit fee: $44.00 Administrative Fee: ]ADMIN $41.00 Work Without Permit? 0 Yes 0 No $0.00 Travel Documentation Fee: I TRA VDOC $44.00 A I CBSC IBSELSAMI]CR $0.50 Select an Administrative Item BBSC $1.00 ---- ----- SUBTOTALS: $156.501 $0.00 TOTAL FEE:FE _$2�6.5O Revised: 1/19/2012 GENERAL PERMIT APPLICATION M = P COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION a 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408)777-3228 • FAX(408) 777-3333 •building(a�cupertino.org MISC CUPERTINO LUNBING MCAL ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS Y, �J� I �P , APN k 0 2" OWNER NAIL /� r PHO E-MAII CITY, TAD&� FAX STREET ADDRESS �Z C G U C( 0 CONTACT NAME , PHONE E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACT' V \W LICENSE ER _ L tII$$ E� BUS.L.IC�A COIviPANYNAME 'V 1 �,�Vrr E ,WA` JV11�.0 FAX v111f�'��'J-(t$�� STREET ADDRESSI n CrIY.STATE�IP_,•\ �✓� PE[ L�� ARCHITECT/ENGINEER NAME J(�(/ �'{ LICENSE NUMBER BUS.LIC k COMPANY NAME (� E-MAL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF FD or Duplex ❑ Multi-Family PROJECT IN WI LDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No DESCR1P7ION OF WORK 40 601100 V&0- TOTAL VALUATION: __4610 GOrAEGEL�(ELTBY Ji4�t "„tom s�_s- rs, By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information JbI videl is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating toing/gb-nstruction. I authorize representatives of Cupertino to enter the ov idle�property for inspection purposes. Signature of Applicant/Agent: '�` Date: _ SUPPLEMENTAL INFORMATION REQUIRED r r. ,s'.� s N ' — � .arm• F'; MEPMiscApp_2011.doc revised 03/16/11