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12070014 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20127 APPLE TREE LN CONTRACTOR:VALLEY HEATING& PERMIT NO: 12070014 COOLING OWNER'S NAME: MATHUR DEVINDRA AND RAKHI 1171 N 4TH ST DATE ISSUED:07/02/2012 OWNER'S PHONE: 4084801404 SAN JOSE,CA 95112 PHONE.NO:(409(294-6290 LICENSED CONTRACTOR'S DECLARATION r r r �7 aBUILDING PERMIT INFO: BLDG ELECT PLUMB License Class ('-.20 Li,.4 . L S O-�C-(C7 r r r �� MECH RESIDENTIAL COMMERCIAL Contractor VR�l i, - Datc- 1 hereby affirm that 1 am licensed_u der the provisions of Chapter 9 JOB DESCRIPTION: REPLACE FURNACE.WITH NEW HVAC UNIT SAME (commencing with Section 7000)of Division 3 of the Business&Professions LOCATION 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 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. I have and will maintain Worker's Compensation Insurance,as provided for by Sq,Ft Floor Area: Valuation:$7460 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:31633092.00 Occupancy Type: 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 slate laws relating to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 2 9.18- Issued by: — Date: '/ L Signalurc lilt ale M?//2 ❑ OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material bong installed.If a roof is 1 hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. I,as owner of the properly,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(See.7044, Signature of Applicant: Date: Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec,7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1 hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE I have and will maintain a Certificate of Consent to self-insure for Worker's 1 have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California I leallh&Safety Code,Sections 25505,25533,and 25534. 1 will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the lleallh& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should 1 store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air permit is issued 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 I certify that in the performance of the work for which this permit is issued,I shall health&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this cenificate of exemption,IO�$Iter or tut It jDg�enl: 7/2/2 become subject to the Worker's Compensation provisions of the Labor Code,I must : ��t%� �ate: forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and slate that the above information is for which this permit is issued(Sec,3097,Civ C.) correct.1 agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may acerae against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION 172 ADDRESS: 20127 apple tree dr. DATE: 07/02/2012 REVIEWED BY: bobs. APN: BP#: 'VALUATION: $7,460 "PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY PENTAMATION USE: SFD Of DUpIBX PERMIT TYPE: FURN/At; WORK re lace furnace with new hvac unit same location. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Furnace, Forced-Air 1MFR=<100 1 # $133 TOTALS: $133.00 Meeh. Plan Check 0.0 hrs $0.00 I'llwd" I'lm,(71, A Elrr. Phos('k,, r Mech. Permit Fee: IMPERMIT l'Irunh_ I......l Fr..- Other Mech. I nsp. 0.0 hrs $45.00 Ulfio Ph"nt,bvop_ �hGrr'lir,,. /uy�. El 1h,h Li•p. /tir- _ Phnuh. Imp. Fe". h:fcc Lr,p_ l'.'rr 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 the De t or adrin'I info. FEE ITEMS (Fee Resolution 11-059 EB: 7/1/1 U FEE QTY/FEE MISC ITEMS Platt r_lw(k 14r: .Slfppl P(-/ cc. PME Plan Check: $0.00 l'clinil /.,n.. Suppl_ hl.,p l cc PME Unit Fee: $133.00 PME Permit Fee: $45.00 Administrative Fee: ]ADMIN $42.00 Work Without Permit? C) Yes Q No $0.00 .I rlr,incrJ 1'l�uulim' l eus: Travel Documentation Fee: 1TRAVDOC $45.00 i Strong Motion Fee. IBSEISMICR $0.75 Select an Administrative Item 131du Skis Commission Fee: 1BCBSC $1.00 SUBTOTALS: $266.75 $0.00 TOTAL FEE: $266.75 Revised: 07/01/2012 2e�--7 U CD I L+ GENERAL PERMIT APPLICATION :31 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO.CA 95014-3255 CUPERTINO (408)777-3228-FAX(408)777-3333•buildino(Dcupertino-oro MISC ❑PLUMBING MECHANICAL ELECTRICAL ❑MISCELLANEOUS /� PROJECTADDRESS n Iree ]� APNv / ( I D � C) CA OWNERNAMP, �` t 1 PHONE n� ,qq,D /qcy E-MAIL STREET ADDRESS / CITY. STlkTH,L.IP FAX ZG12 i /t ! Tree br C� '7 CONTACI- ?AME. PHONE EMAIL STREET ADDRESS CITY,STATE,LIP FAX 11 OWNER OWNER BUILDER ❑ OWNERAGENT ❑ CON'JA ,S ACTON jACO}TRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TF.SANT CONTRACTOR Sry�NlE - 4 \ / /PO /r^ LICENSE NUMIR.G L, 0 LICE\ T)PE BUS LIC d / qr 'qeCOMPANY NA,\\IVVC/ (r [•J ` r r(' E-MAIL �!J J FAX . STREET ADDRESS•' I�� CITY.�\GE,C IP fi f r��//� PHONI:,`O�,` -/ T ft. ARCHITECDENGINEER NAME (-� LICENSE NUMBER BUS.LI_Cry r1 l COMPANY NAME EMAIL FAX STREET ADDRESS CITY,STATE,LIP PHONE USE OF PjSFDor DUPLE% [3 MULTI-FAMILY PROJE7INW'ILDLAND ❑ YES PROJI!('T]..\ ❑YES IS THE KOGAN ❑ 1'ES BUILDING ❑COMMER('IAI. URBAN Ps FACEAREA ❑11 NO FLOODZONE ❑NNO(/1/ � /EICDLERHOME" ❑ so DF.SCRIITN' IOOF\\'ORA Kp h l (( 5a/ll �D(•11 (%z f,'4%• ! e •llltl / N� TOTALVALUATION. ` '7Y ,6— RECEIVED BY. 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(his application and the information I have provided is correct. I have read the Description of Work and verily it is accurate. I agree m comply with all applicable local ordinances and state laws relating to building cons - n. I au hon •representatives of Cupertino to enter the above-idenlilied property for inspection purposes. V . (571021206Z. Signature of Appficant/Agcnt: Date SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY i OVERIRE-COUNTER �y' ❑ EXPRESS U ❑ STANDARD U L < ❑ LARGE 0 ❑ MAJOR ,176-PAfiscApp_2011.doc revised 0621111