12090255CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10660JOlINSONAVC
CONTRACI'OR: VALLEY I[EATING &
PERMITNO: 12090255
COOLING
OWNER'S NAME: CHRISTINE HANSEN
1171 N 4TH ST
DA'Z'E ISSUED: 09282012
OWNER'S PHONE: 4082559471
SAN JOSE, CA 95112
PDONE NO: (408)294-6290
t"r LICENSED CONTRACTOR'S DECLARATION
.1011 DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL
License Class L' _Lic.k 2585u0
REMOVE AND REPLACE 2 WALL FURNACES IN SAME
-a
LOCATION FRONT ROOM AND HALL
Contractor 7` Date
hereby affirm that 1 am license under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
1 herebv affirm under penally of perjun 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
Sq. Ft Fluor Area:
Valuation: $3290
performance of the work for which this permit is issued.
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
AIT Number: 37528022.00
Occupancy Type:
permit is issued.
APPLICM\ 1' 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 Imus 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
LAST CALLED INSPECTION.
I8077Date:
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of thegranting
of this permit. Additionally, the applicam underst.mds mid will comply
Issued by':
with all non -paint source regulations per the Cupertino Municipal Code, Section
9.18.
%J
RE -ROOFS:
Signature Signature•�+Q�t e ✓ ate
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.
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
hereby affirm that I am exempt from the Cantraykhr s hicensr hnw fur one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS'S" 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
IIA%\RDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth & Safety Code. Sections 25505. 25533, and 25534. 1 will
1 hereby affirm under penalty of perjure one of the following three
maintain compliance with the Cupertino Dlunicipal Code, Chapter 9.12 and the
declarations:
Ilealth & Safety Code, Section 25532(x) should 1 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 1
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 Ilealth & Safety Code, Sections 25505. 25533, and 25534
Section 3700 of the Labor Code, for the performance of the work for which this
Owner r
permit is issued.
or authorized agent:
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
CONSTRUCI10N LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
1 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.
st'ork'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
correct. I agree to comply with all city and count, ordinances mid state Imus relating
to building construction, and hereby authorize representatives ol'this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
ARCIIITECI"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
1 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
Iv'MRA FEE ESTIMATOR—BUILDING DIVISION
19ADDRESS:
10660 Johnson Ave
DATE: 09/28/2012
REYIENYED BY: Sean
UNITS
1 APN:
BP#:
'VALUATION:
$3,290
*PERMIT T1'PE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
SFD or Duplex
$266
PENTAMATION FURNIAC
USE:
PERi1IIT TYPE:
YORK
Remove and replace 2 wall furnaces in same locations front room/hall).
SCOPE
$266.00
APPLIANCE / EQUIP TYPE
FEF. ID
Plumb. Plan Cheek
Q'I'1'
UNITS
BP FEES
Flee. Permit rue:
Furnace, Gravity -Type
1MFR=<100
Other rice. Insp.
2
#
$266
Permit Fee:
SuppL Insp Fee
PME Unit Fee:
$266.00
PME Permit Fee:
$45.00
Consit7iction Tax:
Administrative Fee: t tD,tnv
$42.00
Work Without Permit? O Yes Q No
$0.00
TOTALS:
Travel Documentation Fee: ITRAFDOC
$266.00
Strone Motion Fee: 111SEISMICR
NOTE: This estinmte does not includefees due to other Departments (i.e. Planning, Publtc worR.c, Fire, aonrary Sewer ursrricr, acnoan
r.C.. _
Cr. _.....r _...r.,......r_.:..,,.., :..r ....,..:,,...r,,..a..u., n„d..r,. n.rh. on eainvue. Contact fire Dent for arldn'l info.
....,,,.,. . ,. �..< <..... .................... _ .. ..... ,
FEE ITEMSLFce Roolulion /1-053 Ef.'7/1111)
Mech. Plan Check 0.0 Ins $0.00
Plumb. Plan Cheek
glee. Plan Check
Mech. Permit Fee: I h1PF-R,il/T
Flamh. Pv ,, Pae:
Flee. Permit rue:
Other Mech. Insp. 1 0.0 hrs $45.00
Other Plumb Insp.Ll I
Other rice. Insp.
ddech. Insp. Fee.:
Plumb. hnap. ree:
F.lce. Insp. ree:
NOTE: This estinmte does not includefees due to other Departments (i.e. Planning, Publtc worR.c, Fire, aonrary Sewer ursrricr, acnoan
r.C.. _
Cr. _.....r _...r.,......r_.:..,,.., :..r ....,..:,,...r,,..a..u., n„d..r,. n.rh. on eainvue. Contact fire Dent for arldn'l info.
....,,,.,. . ,. �..< <..... .................... _ .. ..... ,
FEE ITEMSLFce Roolulion /1-053 Ef.'7/1111)
..... ..
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
Sapp/. PC Fee
PME Plan Check:
$0.00
Permit Fee:
SuppL Insp Fee
PME Unit Fee:
$266.00
PME Permit Fee:
$45.00
Consit7iction Tax:
Administrative Fee: t tD,tnv
$42.00
Work Without Permit? O Yes Q No
$0.00
Advanced Planning Pies:
Travel Documentation Fee: ITRAFDOC
$45.00
Strone Motion Fee: 111SEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$399.50
$0.00
TOTAL FEE:
F$399.50
Revised: 07/01/2012
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 II11 'l M I
SC
(408) 777-3228 • FAX (408) 777-3333 • building�cupertino.orq
OtA'
-UMBING PKrCHANICAL ELECTRICAL ❑MISCELLANEOUS
PROJECTADDRESS .0 8
APN9 2— (9 va
OWNER NAME
L/Jn' fla�s'eti
PHONE
'i08-255- °(`7/
E-MAIL
STREET ADDRESS
CITY. STATE ZIP/^SG/�r FAN
G.� ,S . 7 -T
CONTACT NAME
See fan it ler
PHONE
E-MAIL
STREET ADDRESS
CITY. STATE ZIP
FAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT
❑ CONTRACTOR CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME�/ /
e'k
LICENSENUMBER
z585qG
LICENSETYPE
c-Za
BUS. LICK
/Yl
COMPANYNAME /I it
E-MAIL
FAX
yah -29y -72y7
STREET ADDRESS
i.
CITY•STATE.ZIP
PHONE
`i69'.29K -4290
ARCHI'rECT/ENGINEER NAME. /
LICENSENUAIBER
BUS. LIC4
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY. STATE. ZIP
PHONE
USE OF FD or DUPLEX ❑ SIULTI-FAMILY
BUILDING: ❑COMMERCIAL
PROIECTINWILDLAND ❑YES
URBAN INTERFACE AREA 'NO
PROIECI'IN ❑YES
FLOOD ZONE �NO
IS THE BLDG AN ❑ t'ES
EICHLER HONIV. O
DESCRIPTION OF WORK
941Z (2)
l"flL'4I1 /S 2 SG^C �Q:af••o,�S i��c+rircort�/u,��
TOTAL VALUATION: 324v—
RECEIVED BY:
By my signature below. I certify to each of the following:
application and the information I have provided is cortect.
ordinances and state Lars relating to building construction.
Signature of Applicant/Agent:
I am the property owner or authorized agent to act on the property owner's behalf. I have read this
I have read Ibe Descripl ion of Work and verify it is accurate. I agree to comply with all applicable local
I aulhor'n representatives of Cupertino to enter the above -identified property for inspection purposes.
Date 1/2 2
SUPPLEMENTAL. INFORMATION REQUIRED
OFFICE USE ONLY
F6
OVER=rUE-COUNTER
—
'1
❑ EXPRESS
—
U
❑ STANDARD
i
El LARGE
❑ MAJOR
MEPAfiscApp_201 /aloe revised 06Q1/11