12060161 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20333 NORTHCOVE SQ CONTRACTOR:A&H HEATING PERMIT NO: 12060161
OWNER'S NANIE: GOMEZ JOSE R 770 CHESTNUT ST DATE ISSUED:0627/2012
OWNER'S PHONE: 4089967858 SAN JOSE,CA 95110 PHONE NO:1308)279-0722
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class `�20 Lic.q '?�o Ce'Ce 7`L
%-. �, MECH r RESIDENTIAL r COMMERCIAL r
Conlracmrw at, (%�� `j2
1 hereby affirm that l am licensed under the provisions of Chapter JOB DESCRIPTION:REMOVE AND REPLACE EXISTING A/C SYSTEM
(commencing with Section 7000)of Division 3 or the Business&Professions
Code and that my license is in full farce and effect.
I 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 Labor Code,for the
performance of the work for which this permit is issued. Sq.FI Floor Area: Valuation:$5000
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
permit is issued. APN Number:31641068.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and slate that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK 1S NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accme 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 Issued by: �+�/1V �TG Date: b-d/-7
-Ja
9.18. / r�
�Signaturc
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 remove all new materials for
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
1,as owner of the property,or my 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(See.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
1 hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE:
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Cenifieaw 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 compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,us provided for by Additionally,should I use equipment or devices which emir 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 1 will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued.
I certify that in the per(oranHealth&Safely Code,Sections 25505,25533,and 25534.ce of the work for which This permit is issued,I shall ,r
not employ.any person in any manner so as to become subject to the Worker's Ower o IhQ agent: J / iL�_/
Compensation laws of California. If:after making this certificate of exemption,I `f, / Date: 1'
become subject to the Worker's Compensation provisions of the Labor Code,I must Irl
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 perfommnce of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and stale that the above information is Lender's Name
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 Lender's Address
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 ARCIIITF.CT'S DECLARATION
granting of this peril.Additionally,the applicant understands and will comply 1 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
FEE ESTIMATOR— BUILDING DIV ISION
ADDRESS: 20333 Northcove Sq I DATE: 06/27/2012 REVIEWED BY: Sean
APN: BP#: 'VALUATION: 1$5,000
=PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Du lex PENTAMATION FURN/AC
USE: p PERMIT TYPE:
WORK Remove and re lace existing A/C system.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
A/C Units (<=10K cfm) 1BREMAIR 1 # $65
TOTALS: $65.00
Meeh. Plan Check 0.0 hrs $0.00 Plumb. Plan Cbcek Plee. Plum Chrck
Mech. Permit Fee: IMPERMIT !'Iamb. Permit Fee: ISler. Permit Fre:
Other Mech. Insp. 0.0 1 hrs $44.00 Other Plumb In,p. Other l.'Ier. htep. Li
A tech. Imp. lhEz•: Plumb. h>,rp. Fee: lifer, bzgt. rix•:
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 prelimina information available and are only an estimate Contact lite De f or addn't info.
FEE ITEMS (Fce Resolution 11-053 E1T. ELI 11 FEE QTY/FEE MISC ITEMS
Plan Chuck Fuc:
Suppl. PC Fru
PME Plan Check: $0.00
Pcrinit Erre:
suppl. ht.cp Fee
PME Unit Fee: $65.00
PME Permit Fee: $44.00
Consnauvion l'a.c:
Administrative Fee: IADMIN $41.00
Work Without Permit? O Yes 0 No $0.00
Advelm ed Maiming bees:
Travel Documentation Fee: ITRAVDOC $44.00 A
Stone Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
131da Stds Commission_ Fee: IBCBSC $1.001 1
r' SUBTOTALS: $195.50 $0.00 TOTAL FEE:' $195.50
Revised: 06/30/2012
0 ( � �
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 M I
CUPERTINO (408)777-3228 • FAX(408)777-3333 •buildinclecuoertino.ora r\/
IC
❑PLUMBING Iffi MECHANICAL BLECTRICAL []MISCELLA-NEOUS
PROTECT ADDRESS 2 o 3/3'3� /V o rgrk cove �� APN a - / . Z)
OWNER NAME 31 r�lv e 6-U 7858{e z E.MAE
U �_J y 6
STREET ADDRESS 33 3 /7v�rJ Y�Ct/�T fir• Sr 1�ZlP�Lrl a w^ rj�- ' FAX
CONTACT NAME a-_a., nS PHONE C/T I)E�E
C 1
STREETADDRESS CITY,STATE ZIP I FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ® CONTRACTOR ❑CONTRAMRAGEfT ❑ ARCHTcC7 ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRALTO / � 0- �^,�/L-�1 U_p)L✓,r�'a�1'q'I BUS
C/L^JC/�1
f � 1-h
COMANNAMAWW�
STREET ADDRESS? O CIlY.SfATE� tOCU
AACQER/EN(WFER
NAME LICENSE MRN®ER BUS.LICA
CONIPANY NAME /-I E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑ SFD or Duplex Multi-Family PRORCr1NWu�tAND PROTECT LN
STRUCTURE: ❑ Commetcial URBAN INTERFACE AREA ❑ Yes No FLOOD ZONE ❑ Yes NO
DESIX➢PTTON OF WORK
TOTAL VALUATION: Sv00 s�ier �ar� - n' "-"R .j
By my signature below,(certify to each of the following: I am the property owner or authorized agent w act on the property owner's behalf. I have read chis
application and the information I have provided is cAnecL I have teed the Description of Work and verify it is accurate. l agree to comply with ail applicable local
ordinances and state laws relating to b ildi nstruction. I authuri=representatives of Cupertino to enter the ab/cove-identifire'd�prope{r'�)for inspection purposes.
Signature of Applicant/Agene Date: (e /1 L L—
S PLEMENTAL INFORMATION REQUIRED _ . .....
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MEPMirrApp_2011.doc revised 03/16/11