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09070141 CITY OF CUPERTI vO BUILDING PERMIT BUILDING ADDRESS: 10575 MERRIMAN RD CONTRACTOR:VALLEY HEATING PERMIT NO:09070141 &COOLING VNER'S NAME: MIKE JERBIC 1171 N 4 TH ST DATE ISSUED:07/20/2009 OWNER'S PHONE: 4082571648 SAN JOSE,CA 95112 PHONE NO:(408)294-6290 LICENSED CONTRACTOR'S DECLARATION I— f— BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Agf r f— r MECH RESIDENTIAL COMMERCIAL ContractorDate Sr /7 1 hereby affirm th t am license under the provisions of Chapte 9 JOB DESCRIPTION: REPL FURNC&A/C (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.Ft Floor Area: Valuation:$8085 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 APN Number:34216136.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that 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 state 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 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 Issued by: Date: with all non-poin ource regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: .gnature Date 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. ❑ OWNE BUILDER DECLARATION ''-- rr Signature of Applicant: VW 1 1A)Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,as owner of the property,or my employees 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.7044,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. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)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 emit 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 I performance of the work for which this 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&Safety Code,Secti s 255 P 5,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this oo permit is issued. Owner or authorized agent: Date:O 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 California. If,after making this certificate of exemption,1 CONSTRUCTION L NDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I mu,,t 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. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is -otrect.I agree to comply with all city and county ordinances and state laws relatin; 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 accrue against said City in consequence of the I 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 CUPERTIPIO BUILDING PERMIT BUILDING ADDRESS: 10575 MERRIMAN RD CONTRACTOR:VALLEY HEATING PERMIT NO:09070141 &COOLING OWNER'S NAME: MIKE JERBIC 1171 N 4 TH ST DATE ISSUED:07/20/2009 OWNER'S PHONE: 4082571648 SAN JOSE,CA 95112 PHONE NO:(408)294-6290 ❑ LICENSED CONTRACTOR'S DEE/CjLARATION BUILDING PERMIT INFO: BLDG ELECT r— PLUMB r License Class Lic.# ! // S MECH RESIDENTIAL COMMERCIAL Contractor ��n� �- Date JOB DESCRIPTION: REPL FURNC&A/C I hereby affirm that I gm licensed under the provisions of Chapter (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.Ft Floor Area: Valuation:$8085 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 APN Number:34216136.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that 1 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 state 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 liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the Issued b Date granting of this permit. Additionally,the applicant understands and will comply all non-point source regulations per the Cupertino Municipal Code,Section RE-ROOFS: Signature Date Q 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. 11 .1.,ZDECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one(f the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,as owner of the property,or my employees with wages as their sole compensatio>>, will do the work,and the stricture 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.7044,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. 1 will 1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)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 emit 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 I performance of the work for which this 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&Safety 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: Date: 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 CONST UCTION LENDING AGENCY 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 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. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address !ify that I have read this application and state that the above information is .ct.I agree to comply with all city and county ordinances and state laws relating ouilding construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I 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 BUILDING DIVISION PERMITNPMI� * BUILDING ADDRESS: PERMIT NO. 10575 MFRRTMAN RD VALLEY .14-FATING, (MOT-ING 0907n1 ,41 OWNER'S NAME: PERMIT L95UE DATE O A CONTROL NO. 408 291-6290 ARCHITEC r/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 900 ICENSED CONTRACTOR'S DECLARATION Job Description m I hereby affirm that I am licensed under provisions of Chapter 9(commencing Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and eff ��`� RE P L FU"RNC & A/C Z License Class Lic.N a n E,O Date Contractor ARCHITECT'S DECLARATION -� I understand my plans shall be used as public records �C6 C0y Licensed Professional OWNER-BUILDER DECLARATION MI hereby affirm that 1 am exempt from the Contractor's License Law for the following reason.(Section 7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,'improve,demolish,or repair any structure y Z prior to its issuance,also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation y H (commencing with Section 7000)of Division 3 of the Business and Professions Code)or y that he is exempt therefrom and the basis for the alleged exemption.Any violation of 88085 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not more than five hundred dollars($500) ❑1,as owner of the property,or my employees with wages as their sole compensation, 3421613 . 00 will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law does not apply to an owner of Ll P property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale.If, however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li. cense Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. ❑I am exempt under Sec. B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ghave and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Worked Compensation Insurance carrier and Policy number are: Carrier. Policy No.: 'L%RTIMCATE OF EXEMPTION FROM S' COMPENSATION INSURANCE (chis section need not be completed if the permit is for one hundred dollars($100) or Icss.) 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 Workers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must 0 forthwith comply with such provisions or this permit shall be deemed revoked. Z""' CONSTRUCTION LENDING AGENCY (..h hN.n I hereby affirm that there is a construction lending agency for the performance of pC 5 the work for which this permit is issued(Sec.3097,Civ.C.) WW 0 Lender's Name Z Lender's Address U C) I certify that I have read this application and state that the above information is LL►" correct I agree to comply with all city and county ordinances and state laws relating to Vbuilding construction,and hereby authorize representatives of this city to enter upon the Uabove-mentioned property for inspection purposes (We)agree to save,indemnify and keep harmless the City of Cupertino against ►F-h rn liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit r" APPLICANT UNDERSTANDS WILL COMPLY WITH NON-POINT Issued by: Date SOURCE R ti�� 07 Re-roofs " r)�Nlf rpplicant ontractor Date � ARDOUS MATERIALS DISCLOSURE Type of R)of or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safely Code,Section 25532(x)? All roofs,hall be inspected prior to any roofing material being installed. ❑Ya Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safciy Codc,Sections 25-V.25533 and 25534.I understarhd that if the building v / does not currently ant ht is my responsibility to notify the occupant of the requirements prior to o a f cupanry. Sign a X'40cant Date r Owner au o' d ent Date All roof coverings to be Class'V'or better CITY OF CUPERTINO 7 ITEMS OF 7 PERMIZ RECEIPT OPERATOR: patg COPY # 1 Sec : Twp: Rng: Sub: Blk : Lot: APN . . . . . . . . : 34216136 . 00 DATE ISSUED. . . . . . . : 07/20/2009 RECEIPT #. . . . . . . . . BSC00008227 REFERENCE ID # . • . : 09C70141 SITE ADDRESS . . . . . : 10E75 MERRIMAN RD SUBDIVISION . . . . . . CITY CUFERTINO IMPACT AREA . . . . . . OWNER MIP.E JERBIC ADDRESS 10E75 MERR8IMAN RD CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3921 RECEIVED FROM . . . . : VALLEY HEATING & CO CONTRACTOR . . . . . . . : ATFINSON, THOMAS LIC # 141 COMPANY VALLEY HEATING & COOLING ADDRESS 111 N 4 TH ST CITY/STATE/ZIP . . . : SAIF JOSE, CA 95112 TELEPHONE . . . . . . . . : (4C8) 294-6290 FEE ID UNIT QUANTITY 114OUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- -- -------- ---------- ---------- ---------- 1BCBSC VALUATION 8, 085 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 8, 085 . 00 0 . 90 0 . 00 0 . 90 0 . 00 1EPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 1MPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 1MRRAA UNITS 2 . 00 126 . 00 0 . 00 126 . 00 0 . 00 1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 -- -------- ---------- ---------- ---------- TOTAL PERMIT 295 . 90 0 . 00 295 . 90 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 295 . 90 #19411 --------------- TOTAL RECEIPT 295 . 90 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL ()qo-7 C CITY OF CUPERTINO FURwACE/AC CUPEk ANO PERMIT APPLICATION FORM APN# �L/� 1 �� � � � cS � Date: Building Address: Owner's Name: Phone#: /, ke Je.r1- q60 I 7 -/( Contractor: Phone#: Fax#: Contractor Wcense#: Cupertino Business License#: Contact: Phone#: Fax#: Building Permit Info: Elect L_'J Plumb �/ Mech Residential Commercial ❑ Job Description: For Aeside tial Installati s: Attic 15t floor [] 2 ' floor ❑ Adhere to minimum setback requirement For Commercial Installations: Replacement same weight F-1 Additional weight(structural calcs) ❑ Structural Calculations required for new installation ❑ New installation Planning Approval Required ❑ Cost of Project: Type of Construction(Usage Class): k,/13 Strapped ❑ On Platform ❑ Bonded ❑ New Location ❑ Replacement Valuation: Green Building: Must attach Green Building CL eck list to this application �Q CITY OF CUPERTINO V` FURVACEAC CITY OF CUPERTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group AIR FURN/AC CONDITIONING 1BCAIRHAN Commercial ,�/C Units <=lOk CFM B 1MCRAA Commercial Mech Repair/alt/add M 1BSEISMICO Seismic Commercial B 1PGASCOM Commerical for ea gas piping System P 1-4 outlets 1PGASRES Residential fcr ea gas piping system P of 1-4 Outlets 1BPGAS For each gas piping system of 5 or P more per.outl:t. Comm/Resid 1BREMAIRHAN Residential A/C units <= IOk CFM B 1MRRAA Residential N:ech Repair/alt/add M IBSEISMICR Seismic Residential B IEPERMITFEE Electric Permit E ' 1MPER1\4ITFEE Mechanical Permit M f IPPERMITFEE Plumbing Permit P ' ITRAVDOC Travel Documentation B 1BUSLIC Business License B Community Development ate 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 ZuKkTINO Building Department JOB ADDRESS: PERMIT# OWNER'S NAME: PHONE # GENERAL CONTRACTOR FAX # I am not using any subcontractors: ,;nature Date Please check applicable subcontra ors and 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 Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile /Contractor Signature Date