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12030156 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10290 WESTACRES DR CONTRACTOF PERMIT NO: 12030156 OWNER'SNAME: HONKAI'fAM S� FI�A 71 IV(r DATE ISSIIED:03/30/2012 yyyOWNER'S PHONE: 6508689350 PHONE NO: tyS LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIALCOMMERCIAL❑ /License Class L210 / Lick e6S'5�} 3 REPLACE FURNACE IN SAME LOCATION Contractor ��M�Q�7 l�1Phn2 rAet Date 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. 1 hereby affirm under penally 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 Labra Code,for the performance of the work for whichthis permit is issued. Sq.Ft Floor Area: Valuation:$1050 1 have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for die performance ordie work for which this APN Number:35911031.00 Occupancy Type: pemhit is issued. APPLICANT CERTIFICATION M G I certify thin I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and stale laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against l iabilities,judgments, 1 costs,and expenses which may accrue against said City in consequence of the �� J 1 -30 granting of this pemtit. Additionally,the applicant understands and will comply Issued by: f �RTG� Date: 1,9— with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. /////��''''' �� RE-ROOFS: SignatureDale Z 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-BIIILDF.R DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Lew for one of Signature of Applicant: Date: the following two reasons: ALL ROOF COVERINGS 7'O BE CLASS"A"OR BETTER I,as owner of the property,or my cnployces with wages as their sole compensation, 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,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7014,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534, [will I hereby affirm under penally of perjury one of the following three maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the declarations: Health&Safely Code,Section 25532(x)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emil hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District l performance of the work for whichthis permit is issued. will maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safely Code,Sections 25505,25533.and 25534. Section 3700 of the Labor Code,for the performance of the work for which this // Owner or authorized agent: Bete: permit is issued I certify that in the performance of the work for which this permit is issued,I shall not employ any person inany manner so as to become subject to the Worker's Compensation laws of California. If after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. w'ork's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 1 certify that 1 have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and stale laws relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may acerae against said City in consequence of the 1 understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18, Signature Date CITY OF CUPERTINO FEE ESTIMATOR -•BUILDING DIVISION ADDRESS: DATE: REVIEWED BY: APN: -BP#i 'VALUATION: $0 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION FURN/AC USE: PERMIT TYPE: WORK SCOPE APPLIANCE/EQUIP TYPE. FEE ID QTY UNITS BP FEES Furnace, Forced-Air iMFR=<100 1 # $130 TOTALS: 1 $130.00 Mech. Plan Check 0.0 hrs $0100 Pl,m,h. I'lm,Check IS7cc. Plop Ckrck Mech.Permit Fee: IMPERMIT Plumb. Pei mil Fee: Iilec.Pennu Fee: Other Mech. Insp. 1 0.0 hes $44.00 Order Plumb Insp. Other Elec./Asp. iter& hmp. Fee: Plumb. lisp. Fre: Oct. lisp. Fcc: 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 pielimina information available and are only an estimate Contact the Dept for addn 7 info. FEE ITEMS (lee Resnlulion 11-053 Eff 711111) FEE QTY/FEE MISC ITEMS Plun Check Pee: .Supp/. PC Fee PME Plan Check: $0.00 Permit pie' .Supp/. /lisp Fee PME Unit Fee: $130.00 PME Permit Fee: $44.00 Conswitetion Tax: Administrative Fee: /ADMIN $41.00 Work Without Permit? O Yes 0 No $0.00 ;Idvoiwed Pluming Fees: Travel Documentation Fee: ITRA VDOC $44.00 Strong Motion Fee: $0.00 Select an Administrative Item Bldg Stds Commission Fee: $0.00 SUBTOTALS: $259.00 $0.00 TOTAL FEE:F $259.00 Revised: 1/19/2012 1 Building Department City Of Cupertino ` 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST X !OB ADDRESS: Z. N + PERMIT# X OWNER'S NAME: r PHONE # 650 — G — GENERAL CONTRACTOR:. f BUSINESS LICENSE# ADDRESS: CA CITY/ZIPCODE: r $ S *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) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR.AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO ` BUSINESS LICENSE. :; X 1 am not using any subcontractors: O 11Z ature Date 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 Heating w Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile I Owner/Contractor Signature Date GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 M I sc CUPERTINO (408)777-3228•FAX(408)777-3333• building aacuoertino.org 03615 LUIVIBING (3'�CHANICAL ELECTRICAL ❑hII5 OUS PROJECTADDRFSSAFNR / 1 2 Qt CA I v OWNERNAMEr PRONE _ E-MAD. O SIREETADDRESS CRY. STATE,Z@ FAX CONTACT NAME PHONE E-MAD. STREETADDRESS CITY,STATE, ZIP FAK ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCTM= ❑ENOLNEER ❑ DEVETL)PER ❑ TENANT CONTRACTOR NAME [� DCENSE NUMBERqcW LICENSE TYPE BUS.DC a COMPANY NAME `� E MAII. FAX STREET ADDRESS yN V eld CITY,STATE,Z� �--,L A PNONE ARCIUTECr/ENGwEER_ NAME LICENSE NUMEE4 (' BUS.GC a COb@ANY NAME e= E-MAIL so O FAx� O• ,`Z nZ STREET ADDRESS CFC(,STATE,IIP - PHONE c o 66 31�=zs o USE OF SFD.OUPL.EX ❑ MULTYFAMD.Y PROJECT IN WODIAND ❑ YES PROJELTw ❑YES MTT¢3LDGAN ❑YFS BUBDwG: ❑COSLMERC4V. URBAN wTflIFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME'. ❑NO DESCRIPTION OF WORK OcAsj O TOTAL VALUATION: (�O RECEIVED BY: By my signamm below,I certify to each of the following: I Run the property owner or authorized agent to am on the property own 's behal ve read this application and the information I have provided is corrtctj have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relatin building cons u representatives of Cupertino to enter the abover identifi property for inspection pufposes. Signature of ApplicmtlAgenn Dare: SUPPLEMENL ORMATION REQUIRED OFFICE USE ONLY W ❑ OVER-THF-COUNTER ❑ EXPRESS Y U ❑ SrA ARO U ❑ L1ROE ❑ MAJOR Iv1EPMucApp_2011.doc revised 06121111