12070153 CITY OF CUPERTINO 13UILDING PERMIT
BUILDING ADDRESS: 7765 IIUNTRIDGE LN CONI'RACI'OR:CALIFORNIA DELTA 11ICRMIT NO: 12070153
MECHANICAL INC
OWNER'S NAME: KATZ RONIT AND ROBERT I 6056 E BASELINE RD STE 155 DATE ISSUED:07/192012
OWNER'S 1'DONE: 4084381785 NI ESA.AZ 85206 I'DONF.N0:(866)692-5273
❑ 1 1ACENSI1D CONI'RACI'OOR'S DECLARATIONr
BUILDING PERMIT INFO: BLDG r ELECT PLUMB r
License Class C---2 0 Lie.N'
N1EC11 r RESIDENTIAL r COMMERCIAL r
Contractor Date 7-Z9 l 2-
1
1 herchv all rdKbal I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:SINGLE FAMILY DWELLING INSTALL NEW HVAC WITH
(commencing with Section 7000)of Division 3 of the Businem S Professions AIC
Code and that my license is in full force and effect. CONDENSOR
I herchv:dTirnt under penally of perjury ane of the following Iwo 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 ollhe work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of Labor Code,for the performance of die work for chich this Sq.FI Fluor Area: Valuation:$3499
permit is issued.
APPLIGWTCF.RTI FICATION AISN Number:35906024.00 Occupant)Type;
I certify that I have read this application and state dial the above information is
correct.I 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 dmahove mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN IRO DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accme against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
With all non-poilt sour regulatiams per the Cupertino Municipal Code,Section
9.18. `�/
7-119Z
/9 7 Issued I Dater
Signa Date
❑ OWNER-BUILDER DECLARATION
RF.-ROOFS:
hereby affirm(hal I nm exunpl from the Conlracmr's License Lin% for one of All mals shall be inspected prior to any roofing material being installed.If a roof is
the following hvo reasons: installed without first obtaining an inspection.I agree to remove all new materials for
I,as owner of the properly,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business.professions Code) Signature of Applicant: Dale:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business R Professions Code). ALL ROOF COVERINGSTO BE CLASS"A"OR BET'I'ER
hcrebp affirm under penally of perjury ane of the fnllmving three
declaralions:
I have and will maintain a Certificate ofConscat to self-insure for Worker's HAZARDOUS JI+\'I'IiRI.\IS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance ollhe work for which this pemiii is issued. California Ilcallh S Safety Code.Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Masicipal Code,Chapter 9.12 and the Health 3
Section 3700 of the Labor Code,for the performance of the work for which this Safely Code.Section 25532(a)should 1 store or handle ha7nrdous material.
Additionally,should I use equipment or devices Which emit hazardous air
permit is issued. contaminants as defined by the IllyArea Air Quality Management District I Will
I certify that in the performance of the work for which this permit is issued.I shall maintain compliance with the Cuperlino Nlunicipal Code,Chapter 9.12 and the
not employ any person in my manner so as to become subject to the Worker's Health&Safety Code.Sections 25505,25533.and 25534.
Compensation laws of Califomia. II;atter making this cenilicale of exemption,I
become Subject to the Worker's Compensation provisions of the Labor Code,I mustDate:
(t` ulhorized a+ ut:—
forthwith comply ith such provisions or this permit shall be deemed revoked. —� 9
WZ
CONSTRUCTION LENDING AGF-NCY
AI'I'LIC.\\I'CF:R'I'IIIC,\'I'll h\
I certify that I have read this application mid state that the above information is I hereby affirm that there is a construction lending agency for the performance of ssork's
correct.I agree to comply with all city and county ordinances and stale laws refuting for nvhich this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Namc
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may license against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCI IITECI"S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. 1 understand my plans shall be used a public records.
Signature Date Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 7765 huntridge In. DATE: 07/19/2012 REVIEWED BY: bobs.
97,14 APN: BP#: 'VALUATION: $3,499
*PERNIIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAM,'LTION FURN/AC
USE: pPERMITTI,PE: At
WORK sfd install new hvac with A/C condensor.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
A/C Units (<=10K cfm) 1BREMAIR 1 # $67
Furnace, Forced-Air 1MFR=<100 1 # $133
TOTA LS: $200.00
Mech. Plan Check 0.0 hrs $0.00 Plumb.Plan Check Elec.Plan Cher.k
Mech. Permit Fee: IMPERMIT Plumb.Permit Pae: F.lec.Permit Fee:
Other Mech. Insp. 0.0 hs $45.00 Other Plumb Insp. El
Other Elec.Insp.
,blech. Insp.Fee: Plumb. Insp.Fee: Elec. Insp.Fec:
NOTE: This wintate does not include jeer due to other Departments(i.e. Planning, Public IfYorks, Fire,Sanitary Server District,School
District,etc.). These ees tire baser/on the prelinjinay3 in ornunion available and are only an estimate. Contact the Dept for atltdn'I info.
FEE ITEMS (Fee Resolution 11-053 E/L 7/1/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Suppl. Insp Fee
PML' Unit Fee: $200.00
PME Permit Fee: $45.00
Con n-action Tax:
Administrative Fee: 1ADMIN $42.00
Work Without Permit? 0 Yes Q No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRAFDOC $45.00
Strome Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Blde Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $333.50 $0.00 TOTAL FEE: $333.50
Revised: 07/01/2012
i2-0-7o I S3
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 950143255 w w /�
(408)777-3228 • FAX(408)777-3333 • buildinD(a)cuoerdno.orD I�I v\
CUPERTINO
❑PLUMBING MMECHANICAL ECIRICAL ❑MISCFLL4NEOUS
PROJECT ADDRESS 7 7 C N APPJ B (OLP
L ^ 0 a
C
OWNERNAME % PHO I E-MAIL
ST REET ADD CRY.STA ZIP _n f0/ FAX
CONTACT NAME PHONE E-MAIL
ADDRESS rtC Cn"Y,STATE. ZIP I FAX
2
OWNER ❑ OWNER-BUIlDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCBTECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
NTRA RNA.ME r L'Cu^JSE NUF9 [UCFNSE E BUS.LC
O /ILL n -trClf r;' ' O S
E-MAIL
A-0&-019 7'11 CJ
03jESS /- r CRY,ST�ZIP O / PHONE
!J h J Y ^�y
ARC 7TECUFNOINEER NAME LICENSE NUMBER I BUS.LIC H
COMPANY NAME' E-MAIL. FAX
STAEETADDRELS I Cr,Y,STATE,ZIP I PHONE
USE OF ❑SFO ar DUPLEX ❑ MULTI-FAMILY PROJECT IN WI DLA413 ❑ YEs PROJECT IN ❑YES IS THE 9LDG AN ❑ YEs
BUILDING: [3 COALNERCTAL URBAN DaTFAFACE AREA NO FLOOD WNE ❑NO I EICHLEt HOME! ❑NO
DESCR 1MON OF WORK
e rep— end <e /P0
TOTAL VALUATION: ZI 9 9. O a I RECEI VED BY: f
By my signan belo cer-�fy m each of the following: I am the property owner or authorized agent to ac-ton the propery owner's behalf. 1 have read this
application and the information I have provided is correct. 1 have read the Description of Work and verify itis accumre. I agree m comply with all applicable local
ordinances and sate laws relating In 'n onstruction. I authorize representatives of Cupertino:o enter the above-idend5ed pmpe.—,/for inspection pu;�oses.
Signatar,of Applicaot/Agen Dar_: /9 —1,2
SL PLEN ENTAL INFORNfATION REQUIRED OFFICE USE ONLY
y OVER-THE-COUNTER
's
❑
EXPRESS
u
❑ STANDARD
U
5
❑ LARcE
❑ ,NWOR
h1E4P,Ntrc4pp_3011.doc revised 06/31/ll
Building Department
City Of Cupertino
10300 Torrc Avenue
GuNcruuVy CA YJV 14--iZDD
Telephone: 408-777-3228
C O P E RT I N O Fax_: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS:. 7 vq7- G PERMIT# —7O /S3
OWNER'S NAME: Z PFIONE#
GENERAL CONTRACTOR: r�cr a ,' / BUSINESS LICENSE#
ADDRESS: 6orf� CITY/ZIPCODE: -4
*Our municipal code requires all businesses working in the cite 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 CUPERTIN_O
BUSINESS LICENSE.
1 am not using any subcontractor
Signature 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
Pleating
Insulation
Landscaping
Lathing,
Masonry
Painting/ Wallpaper
Paving
Plastering
Plumbing,
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date