12090196 CITY OF CUPERTINO 13UILDING PERMIT
BUILDINGADDRESS: 19894Will'ATON DR CONTRACTOR:CONDITIONED AIR PERMITNO: 12090196
OWNER'SNAME: IIARUTYUNOV IOSIFANDTARKIIANYAN ANA 1701 1,11-FIX ORCHARD ST DATE ISSUED:09242012
ON'N'LR'S PIIONE: 4084313230 SAN JOSE,CA 95125 PHONE NO:(408)291-2220
❑ LICENSED CONfRAC-`I'OR'S DECLARATION' BUILDING PERMIT INFO: BLDG I_ ELECT r PLUMB Cl
License Class C-7-6 Lic.9 7 yS/G Z
M
11 (( �,I fip !/ ECIi [ RESIDENTIAL r COMMERCIAL r
Contractor (20L, A,'1 1,8�10N lr.{3alc ? (V-7—(/�Z—
I hereby affirm than ant licensed under the provisions of Chapter 9 •10B DESCRIPTION: REPLACE EXISTING FURNACE IN SAME LOCATION
(corn mencing with Section 7000)of Di%isiam 3 of the Business d Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the fulloaing too declarations:
I have and will maintain a cenificate 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.171 Floor Area: Valuation:$3600
Section 3700 of the Labor Code,for the performance of die work for which this
permit is issued.
\PN\umber:31621082.00 Occupancy'I'}'pe:
APPLIC.\N'1'CER'I'IFIC.CI'It)N
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 Imes relating
to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned properly for inspection purposes. (We)agree Io save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses whichmay 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 regulaC S� m'the mo A ipal Cole,Scdian II �(`c
9.18. u/pin /j Issued by:V�^ Date:
Signature L Dale_/7C
❑ OWNER-BI11LDER DECLARATION RI:ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
1 hereby affirm that I am exempt from the Contractor's License Lamfor one of installed without first obtaining an inspection,I agree to remove all new materials for
the following hyo reasons: inspection.
1,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. Signature of Applicant: Dale:
Business d Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business d Professions Code). At,[,ROOF CO\'F,RINGS TO RF,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 I 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 Ieallh S Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the health S
1 have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(x)should I store or handle hazardous material.
Section 3700 ofthe labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by'the Bay Area Air Quality Management District I will
permit is issued, 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 Cade,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 certificate of exemption,I Ou'ner nr a n izeJ agent:
become subject to the Worker's Compensation provisions of the Labor Code,1 must hate:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTR11C11ON LENDING AGENCY
APPLICANT'CER'1'IFIC,\TION I hereby affirm that there is a construction lending agency for the performance ofvmrk's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ Q
coned.I 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 accrue against said City in consequence of the
granting of this permit,Additionally,the applicant understands and will comply ,\RCII I'I'IiCTI"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
i 2x--)9 019
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228 • FAX(408)777-3333 • building0guoerino.org
misc
❑PLUlvIBING MECHANICAL ❑ELECTRICALLL � ❑MISCELLANEOUS
PROIECT ADDRESS / Y I APN�V � D�
OWNER NAME L OSI ,'V- Aor:g
PHONE D O -- Y�/' � E-MAIL
E MA
/ STREET ADDRESS CITY, STATE.ZIP I FAX
CONTACT NAME PHONE E-MAIL
STREE7ADDRESS - CITY.STATE, ZIP FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER ADEM EI CONTCTOR ❑CONTRACTOR AGENT ❑ ARCIETECT ❑ENGINEER ❑ DEVELOPER [I TENANT
CONTRACTORNAME LICENSE NUMBER LICENSE TYPE^_2�
/. COMPANY NAME E-MAR ` FAX SCJ
STREET ADDRESS CITY.STATE,ZIP PHONE
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ARCHITECF/ENGINEER NAME LICENSENUMBER I BUS.LICA
COMPANY NAME' I E-MAIL FAX
STREET ADDRESS CIT',STATE,ZIP PHONE
USE OF -ZSFD m DUPLEX ❑ MULTI-FAMRY PROJECT IN WI DIAND ❑ YES I PROJECT IN ❑ YES I IS THE BLDG AN ❑ YES
BUII.DNG: E]COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE 0 N EICHLER HOMES 0 N
DESCRIPTION OF WORK
e0 1CAce e-,f(sq, ,Alal cawle
0 C4 0V`
TOTAL VALUATION: Q C6 RECEIVED BY:
By my signal -below,I c d,y to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. 1 have roildds
application and the information I have provided is comeI have read the Description of ork and verify it is accurate. I agree m comply with all applicable local
ordinances and Sate laws relating to buil + g con no suillorize-3,--pr1sentai Cupertino to enter the above-iocrinified p perry for inspection putposes.
Signature ofApolitanOAgene Date: !/ Z
SUPPLEMENTAL TN•FORI'VfATION REQUIRED OFFICE USE ONLY
y ❑ OVER-THE-COUNTER
r
❑ EXPRESS
1
U
❑ STANDARD
V
❑ LARGE
❑ aIMOR
MEP:Nuc,4pp_2011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 19894 Wheaton DATE: 09/24/2012 REVIEWED BY: jsg
97APN: BP#: 'VALUATION: $3,600
*PERIIIFF TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMITTYPE: FURN/A
WORK a lace existing furnace in same location
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTV UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $133
TOTALS: $133.00
Mech.Plan Check 0.0 his $0.00 Phunb. flan Check Flea Plan Check
Mech. Permit Fee: IhIPERMIT Plumb.Permit Fee: Elec.Permit Fee:
Other Meeh. Insp. 1 0.0 hrs $45.00 Other Plumb Insp. 011ier Cage•.fast,.
Hech.hup.Fee: Plumb. lrrep. Fee: Elec.htsp.Fee:
NOTE: This estimate does trot includejees due to other Departments(i.e. Planning, Public B'orks, Fire,Sanitary Server District.School
District,etc.). These fees are based on the prelintinari information available and are ono,ntt estintate. Contact the Dept for adrin'1 in o.
FEE ITEMS (Fee Resolution 11-053 F_lX 7/1/111 FEE QTY/FEE MISC ITEMS
Plan Check Tec::
Suppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Supp/. Insp Fee
PME Unit Fee: $133.00
PME Permit Fee: $45.00
Consniielion Tax:
Administrative Fee: 1ADMIN $42.00
Work Without Permit? O Yes 0 No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRdI'DOC $45.00
Strong Motion Fee: IBSEISVICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee. IBCBSC $1.00
SUBTOTALS: 1 $266.50 $0.00 TOTAL FEE: $266.50
Revised: 07/01/2012