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12110139CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1099 NOVEMBER DR CONIRACMR: IIUSSF:Y BROS INC PFRMIT NO: 12110139 OWNER'S NAME: CULLUM DOUGLAS L AND WENDY L 903 GEORGE ST DATE ISSUED: 11272012 OWNER'S PIIONFi 4084833632 SAN'T'A CLARA. CA 95051 PRONE NO: (408)733-6360 ❑ - LICENSED CONFRACI'OR'S D iCLARATION r r� BUILDING PERMIT INFO: BLDG ELECT PLUMB ri License Class Lie - # !o'l J-G 6 `j r r r NIECII RESIDENTIAL COMMERCIAL Contractor V S{ Biel. Date hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE 2 FORCED AIR FURNACE (commencing with Section 7000) of Division 3 of the Business & Professions Code and that nn' license is in full force and effect. I herehy affirm under penalty 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. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of doe work for which this permit is Issued. API'LICANI' Cl ?R'I'IPICA'1'10N' I certify that I have read this application and state that the above information is 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 upon the above mentioned property for inspection purposes. ( %Ve) agree to save indemnify and keep harmless the City of Cupertino against Iiabilitics,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 with all non -point so a re ulation s per the Cupertino Municipal Code, Section 9A S. Signature Date ❑ OWNER - BUILDER DECLARATION hereby affirm that 1 am exempt from the Contractor's License Law for one of the following two reasons: 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 (See.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to constmet the project (Sec.7044, Business'& Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to setf-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 Section 3700 of the Labor Code, for the performance of doe Work for which this permit is issued ' 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 Imes of Califomia. If, after making this cenifcate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply With such provisions or this permit shall be deemed revoked. 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 state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against ltabil ities, 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 with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date Sq. Ft Floor Area: I Valuation: 54800 APN Number: 36217063.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued b_. Date: %/_, RE- ROOFS: All roofs shall be inspected prior to any rooting material being installed If a roof is installed without first obtaining rut inspection, I agree to remove all new materials for inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO RE CLASS "A" OR I3F;1-1'ER HAZARDOUS MATERIALS DISCLOSURE have read the hazardous materials requirements under Chapter 6.95 of the California Ilealth & Safety Code, Sections 25505. 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code. Chapter 9.12 and the Ilealth & Safety Cade, Section 25532(a) should I store or handle hazardous material. Additionally, should 1 use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Nianagement District 1 will maintain compliance with the Cupertino Municipal Cade. Chapter 9.12 and the' Ilealth & Safety Code. Sections 255115, 25533, and 25534. Owner or au i agent: _L1_/ N__ Date: ^ CONSTRUC11ON LENDING AGENCY I hereby of irnn that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed I CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 950143255 (408) 777 -3228 • FAX (408) 777 -3333 • buildinc0cuDerino.ora [211 MEP I—IPLUTflING A/T--CHAAMCA -L FIELECIRICA -I F11b2SC`LLA.N :DUS M ISC PROIS ADDRESS O� I Q� I IV OWNER NAM' CV O� Ic LPN: Nt.. PHONZ 00 P3 - '3�G,J.(� S i72� -r ADDRESS p N o ve v ,Q ` STATE- i er � To f I FAX CONTACT NAME ST - TADDIka-S PHONE E -N13 CITY. STA -E ZIP FAX ❑ OWNM- ❑ OWNM -WUV' - ❑ OuNER A TRACTOR ❑CONTRACTOR AG=17. ❑ ARGLT_LT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT COWTRACTORN.AME Q j t y V �e I LIC_NS � U S/ I BUS. uC% COMPANYNAE Hvsse ro3 tt,( - -MAR I FAX Q SiRc,ADDRESS 103 GIr., e S C /crza CF} SSa.Sy I PH °NE�o�3-G3Gv A, c=ICTMNGL�= NAME LICENSE NUTf5::R I BUS. llC p CO NVANY NAME I E -NAB. FAX STRE--r ADDRESS I C1TY.STA -I�L7 I ?HOW- USE OF TD m DUPLEX ❑ MULTLFAMRY BV NG: ❑ OoM CLAL PROIECr IN WRDIAND ❑ YS URBAN INTERF-ACE AREA NO PRO rCT III ❑ : S FLOOD ZONE )R-NO S T a BLDG AN ❑ YES MC HOME? gliO DESCA.PFLONO -r WORK (' f TDTAL VALUATION: OO I RECEIVED 9Y: ✓' y my signarz�e below, I eetiy to each of :he iollo ing: i am :he DMperry awner or zuthonzt_d agent to ac: on the prop ery owner's beCal£ I have ;ead his application and the information I have pro�9d- is ooIIe[L I have read the Description of Work and ve. -;y it is xccwxte. I ag; eq to comply with elI applicable local ard:rzTCS and sue¢ laws relating ;o buiidin authorin r-_pr•_sen¢dves of Cuperino to emcr the above den•'Sed oro_ne —.y for irsnec5on pui ?ones. Sig-.2,,a of .A.pplicantlAgent: Date: X, ' ��- L SL-PFLENENTI.AL WFORTLATION RE.QTJ- ED OFFICE USE ONLY m - u V Z r� u-0 'EA-THE -COUNTER ❑ EXPRESS ❑ STANDARD ❑ LARGE ❑ AWOR )v!= ?lduc4pp_2011.doc revised 06/21/11 �� CITY OF CUPERTINO 11►'`S/d FEE ESTIMATOR — BUILDING DIVISION APPLIANCE /EQUIP TYPE ADDRESS: 1099 november dr. DATE: REVIEWED BY: bobs. UNITS APN: '` - BP #: - VALUATION: $4,800 '*PERMITTYPEi Mechanical Permit PLAN CIIECK TYPE: Alteration / Addition / Repair PRIMARY ' SFD or Duplex iy PENTAMATION ' FURN /A i USE: Suppl. Insp Fee PER�11'1' Tl'PE: NVORK 2 Forced air furnace. SCOPE [replace APPLIANCE /EQUIP TYPE FEE ID Plumb, Plan Check QTY UNITS BP FEES - Furnace, Forced -Air 1MFR = <100 Oder Flee. Insp. Ll 2 # $266 iy Permit Fee: Suppl. Insp Fee LP PME Unit Fee: $399.00 PME Permit Fee: $45.00 Construction Tar: Administrative Fee: IADM /N $42.00 Work Without Permit? I) Yes (] No $0.00 TOTALS: Travel Documentation Fee: ITRAVDOC sK9.00 Strong Motion Fee: IBSEISMICR NOTE: This estimate roes not indudejees due to other Departments (i.e. Planning, Public Works. Fire, Sanitary Sewer.Disinct, sdmot n:.a.:..r a n 1 Thom ! ac nrn hnead m• tho nrn /iminnnr inMrrtmni.n nvnihthle and are onh, an estimate Contact the Dent (or addn'I info.. FEE ITEMS (Fee Resohrtion 11 -053 Ef 711112) Mech. Plan Check 0.0 1 hrs $0.00 Plumb, Plan Check F./ec. Plan Check Mech. Permit Fee: IMPERMIT Plumb. Permit Fee: F-lec•. Permit Fee: Other Mech. Insp. 0.0 hrs $45.00 Other Plumb Insp, Oder Flee. Insp. Ll Mech. Insp. Fee: Plumb. hmp. Fee: MCC. last). Fee: NOTE: This estimate roes not indudejees due to other Departments (i.e. Planning, Public Works. Fire, Sanitary Sewer.Disinct, sdmot n:.a.:..r a n 1 Thom ! ac nrn hnead m• tho nrn /iminnnr inMrrtmni.n nvnihthle and are onh, an estimate Contact the Dent (or addn'I info.. FEE ITEMS (Fee Resohrtion 11 -053 Ef 711112) FEE QTY /FEE MISC ITEMS Plan Check Fee: Suppl. PC Fee PME Plan Check: $0.00 Permit Fee: Suppl. Insp Fee PME Unit Fee: $399.00 PME Permit Fee: $45.00 Construction Tar: Administrative Fee: IADM /N $42.00 Work Without Permit? I) Yes (] No $0.00 Advanced Planning Fees: Travel Documentation Fee: ITRAVDOC $45.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Itp Qqq, Blcla Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: 1 $532.50 $0.00 TOTAL FEE: $W.50 Revised: 10/01/2012 ?V