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12050022CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10720 MARTINWOOD WAY I CONDITIONINGTROTFHEATING AND AIR I PERMIT NO: 12050022 OWNER'S NANIE: ERIC CARLSON 1299 CORNING AVE I DATE ISSUED: 05/022012 OWNER'S PHONE: 4088620297 I MILPITAS, CA 95035 I PHONE NO: (408) 7868120 1 la.'_ LICENSED CON'TRACTOR'S DECLARATION icensc Class 0- - Z O Lic, N pL (-7 3 s— ontractor ate 1 hereby affirm that 1 am licthsld 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-insum 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. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of Ute work for which permit is issued. APPLICANT CERTIFICATION 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 slate 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, 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 ource regulations per the Cupertino Municipal Code, Section 9.18. �ignature Dale 2-- 11 OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Lew for one or the following two reasons: 1, as owner of the property, or my employees with wages as their sole compensation, wil I 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 conslmct the project (Sec 7044. Business & Professions Code). 1 hereby affirm under penally of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to sclf-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. 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 this permit is issued. I 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 Compensation laws of Calil'omia. If, after making this certificate of exemption, 1 become subject to the Worker's Compensation provisions of the Labor Code, I must fanhwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that I have read this application and stale that the above information is correct. 1 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 upon the above mentioned property for inspection purposes. (We) agree to save 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 BUILDING PERMIT INFO: BLDG r ELECT I— PLUMB r MECH r RESIDENTIAL f COMMERCIAL r JOB DESCRIPTION: REPLACE FURNACE ADD A/C UNIT Sq. FI Floor Area: I Valuation: $4900 APN Number: 36935032.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAV7trM LAST CALLED INSPECTION. Issue Lb Dale: RE -ROOFS: All roofs shall he 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. Signature of Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE: 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should 1 store or handle hazardous material. Additionally, should 1 use equipment or devices which emit hazardous air 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 Health & Safety Code, Sections 25505, 25533, and 25534. ,Owner o aulhci ' .�ege q / Date: P- 1 CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed ��ft7,�� CITY OF CUPERTINO 11 FEE ESTIMATOR — BUILDING DIVISION APPLIANCE / EQUIP TYPE ADDRESS: 10720 Martinwood DATE: 05/12/2012 REVIEWED BY: jsg UNITS ppN; BP#; VALUATION: $0 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY USE: SFD or Duplex $130 PENTAMATION PERMIT TYPE: FURN/A WORK Replace furnace and add AC SCOPE 1 APPLIANCE / EQUIP TYPE FEE ID I'hm,h. Plou Chrrd QTY UNITS BP FEES h7.:1 I',uv,ir I",:.- Furnace, Forced -Air 1MFR=<100 urh,-r Iid r. I„y EJ 1 # $130 A/C Units (<=10K cfm) 1BREMAIR Supp/. /csp lee 1 # $65 PME Unit Fee: $195.00 PME Permit Fee: $44.00 (,mmi71f7lO i Tax. Administrative Fee: (ADMIN $41.00 Work Without Permit? Yes (j) No $0.00 TOTALS: I I 1 1 $195.00 Stronc Motion Fee: NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School m�..:�. e! rhoso & or aro hated na thn nra/iminaru infnrmation available and are oniv an estimate. Contact the Dept for adfln'l info. FEE ITEMS (l oe R snlmion /1-053 Lill: 7///11) Mech. Plan Check 0.0 hrs $0.00 I'hm,h. Plou Chrrd Phw (.h- Mech. Permit Fee: I MPERMIT PLm,h- Prrmir Frr: h7.:1 I',uv,ir I",:.- Other Mech. lnsp. 0.0 hrs $44.00 urh<-r Pit.nr4 hup. urh,-r Iid r. I„y EJ .Ihe6. bnp-ler. Phuuh. ny' Fr;: $0.00 NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School m�..:�. e! rhoso & or aro hated na thn nra/iminaru infnrmation available and are oniv an estimate. Contact the Dept for adfln'l info. FEE ITEMS (l oe R snlmion /1-053 Lill: 7///11) FEE QT /FEE MISC ITEMS SlIppl, l'C f ir. PME Plan Check: $0.00 PC I ;,l it Fcr: Supp/. /csp lee PME Unit Fee: $195.00 PME Permit Fee: $44.00 (,mmi71f7lO i Tax. Administrative Fee: (ADMIN $41.00 Work Without Permit? Yes (j) No $0.00 .I dnfm rrl PholOng 1'. .s •� A Travel Documentation Fee: ITRAVDOC $44.00 Stronc Motion Fee: $0.00 Select an Administrative Item 131da Stds Commission Fee: $0.00 SUBTOTALS: $324.00 $0.00 TOTAL FEE: $324.00 Revised: 04/01/2012 CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT '• BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) T77-3228 • FAX (408) 777-3333 • buildinO(dcupertino.orO MEP M ISC ❑PLUMBING 12;ECHANICAL ❑FIIECTRICAL FMISCEIrnNEOUS I2_D5 OOZZ FROIECT ADDRESS p.-�/� �arrt�,� wood "'1" 3u � 35 03 OWNER NAME '� 1% �/t l' A TSO (/[r j+ l' PHONE 'Z. ' C>,Lq ' E-MAIL TF � 14 VA, C G Il T �FTjm3eG+ STREETADDRESS JC CrIY. STATE- ZIP C -t%.(10 kr FAX A CONTACT NAME a-. J �� O W �� PHONE !Awn _ O 2 -L p ^ L- T E4WL S1RFF3TTADDRESS CITY. SCAM MF FAX �' ❑ OWNER ❑ OWNER.BUILDER . 13.pr �'OWNERAGENT p-wnTruCTOR ❑COMRACTORACFNT ❑ AR NtrECT ❑ ENORIEEtt ❑ OEVEfAPEA ❑TENANT CONTRACTORNAME IHVAC LICENSE NUMHEA F](. LICENSE MECO BUS. LICA COMPANY NAME �I-� G ENA TlF-rtt Acb�'agoo FAX STAEETADDIMS Z It tl 6Drh12� A ..G GU V /'�:+ CITY. STATE ZIP IV �I Ili`& L.l �/i PHONE 786— JI20 o a ARC}DTECTIENGBJEER NAME LICENSE NUMBER BUS. LIC R COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE. IIP PHONE USE OF ❑SM.DUPIEX ❑ MULTI-FAMD.Y BUDDING: ❑COr-DAr-art.r FR0IEDTDa WBDLAND ❑ YESPROMCTIN URBAN DlI'EJ{FAQ AREA i10 ❑ YES FLOODZONE -ono LSTBEBLDGAN ❑ YES EICHLER 110. I NO DESCRIPTION OF WORK A- G TOTAL VALUATION: g 1 O O I r RECEIVED BY: By my signature belay, I certify to each of the following. I am the property owom or aatherized agent to act on the pmpetty rowers behalf. I have read this application and the information I have provided is correct 6src read the Description of Wark and verify it is acuate. I agree to comply with all applicable local Ordinances and state laws relating to bupcpg coostructirm representatives of Cupertino to enter the above-idHtuSed property for inspection pulposw. Signature of ApplicandAgeac Dare: 6--2—�•+ (a--- SUPPLEN ENTAL 94FORMATTON REQU= OFFICE Use ONLY N VEIL -TUU COUNTER d Id Y ❑ STRESS u u ❑ STANDARD 5 ❑ uacE ❑ MAJOR AMPMucApp_2011.doc revised 06121111 0-