12120110I CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22543 WOODRIDGE CT
OWNER'S NAME: MAU CI- IENG -I AND'fLU =PING
OWNER'S PHONE: 4088575510
LICENSED CONTRACTOR'S DECLARATION
License Class L 2 O Lic. # 'Nut-9 11
Contractor C tZ E"%'Ir Date 0-- ?f� (�--
I hereby affirm that I am licensed u lzr 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.
I hereby 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 the work for which this
permit is issued.
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 relatin'o
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 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
xvith all non -point source regulations per the Cu unicipal Code, Section
9.18.
Signature � Datc I -zfi
❑ AWN A- BUILDER DECLARATION
I hereby i6firrn that I am exempt from the Contractor's license Law for one of
the following two reasons:
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
construct 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 SCI f-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 the 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 laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
forth%\ ith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CF,RTTFICATI0N
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
indemnifN 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
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Sianature
Date
CONTRACTOR: ONE I LOUR I IEA'I'ING AND PERMIT NO: 121201 10
AIR
1400 11 ETA 1,U.N1A 1111, 1, RD DATE ISSUED: 12/20/2012
SANTA ROSA, CA 95404 PHONE: NO: (707) 545 -1800
BUILDING PERMIT INFO: BLDG ELECT PLUMB
MECI4 RESIDENTIAL COMMERCIAL '
JOB DESCRIPTION: INS'I'ALL NGW FURNACE' A'1' 1iXIS "PING LOCATION
Sq. Ft Floor Area: I Valuation: $4087
APP' Number: 34215062.00 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE, OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued byy Date:
RE- ROOFS:
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 neti i aterials for
inspection. j
Signature of Applicant Date:
ALL ROOF COVF,J}1 4i1 TO 13E CLASS "A" 012 BETTER
IIAZARDOUS MATERIALS DISCLOSURE.
1 have read the hazardous materials requirements under Chapter 6.95 of the
California health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the health &
Safety Code, Section 25532(a) should 1 store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
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
{Health & Safety Code, Sections 25505, 25533, and 25534.
Owncr or authoyfecta
CONSTRUCTION LENDING A(,ENC1'
I hereby inn 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 Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
CUPERTINO (408) 777 -3228 • FAX (408) 777 -3333 • building(_Wcugertino.org
❑ PLUMBING ❑ MECHANICAL ❑ELECTRICAL I-I MISCELLANEOUS
t 2(z � t 0
MEP
MISC
PROJECT ADDRESS ��7 �
/
APN�.3/ J &
OWNER NAME
PHONE• �,-
S
E -MAIL
STREET ADDRESS
z2 rj ✓'CJ�i2I17vl ��°
CITY, STATE, ZIP �./•
C-�✓t>L1Z_T /A)0
FAX
CONTACT NAME KIM LAPORTA
PHONE 707 -545 -1800
E -MAIL
STREET ADDRESS 1400 PETALUMA HILL RD
CITY, STATE, ZIP SANTA ROSA,CA 95404
FAx
❑ OWNER ❑ OWNER - BUILDER ❑ OWNER AGENT
CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
ONE HOUR HEATING AND AIR
LICENSE NUMBER
740999
LICENSE TYPE
C20
BUS. LIC #
COMPANYNAME ONE HOUR HEATING AND AIR
E -MAIL
FAx 707- 523 -1803
STREET ADDRESS 1400 PETALUMA HIULL ROAD
CITY, STATE, ZIP SANTA ROSA, CA 95404
PHONE 707 -545 -1800
ARCHITECT /ENGINEER NAME
LICENSE NUMBER
BUS LIC #
COMPANY NAME
E -MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF FD or DUPLEX ❑ NFULTI-FAMIL77
BUILDING ❑ COMMERCIAL
PROJECT IN WILDLAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD ZONE ❑ NO
IS THE BLDG AN ❑ 7S
EICHLER HOME` ❑ NO
DESCRIPTION OF WORK I , - r.
C — I U O2 J At:f it
7,
C_
TOTAL VALUATION: a
RECEIVED BY: 4,
By my signature below, I certify to each of the following:
application and the information I have provided is correct.
ordinances and state laws 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 the Description of Work and verify it is accurate. I agree to comply with all applicable local
I authorize representatives of Cu to enter the above - identified property for inspection purposes.
Date:
PPLEME
ORMATION REQUIRED
OFTICjVSE ONLY
W
OVER- THE - COUNTER
a
❑ EXPRESS
W
CC
❑ STANDARD
U
z
❑ LARGE
a
❑ MAJOR
MEPMiscApp_201 1. doc revised 06/21/11
rr___M7 CITY OF CUPERTINO
FFF ESTIMATOR — BUILDING DIVISION
APPLIANCE / EQUIP TYPE
ADDRESS: 22543 woodridge ct.
DATE: 12/20/2012
REVIEWED BY: bobs.
UNITS
APN:
BP #:
*VALUATION: 1$4,087 -�
xPERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
I
PENTAMATION FURN /AC
I PERMIT TYPE:
WORK
install new furnace at existing location.
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY /FEE
QTY
UNITS
BP FEES
Furnace, Forced -Air
1MFR = <100
1
#
$133
PME Unit Fee:
$133.00
PME Permit Fee:
$45.00
Administrative Fee: IADMIN
$42.00
Work Without Permit? 0 Yes (F) No
$0.00
TOTALS:
Travel Documentation Fee: ITRAVDOC
$133.00
Strong Motion Fee: IBSEISMICR
Mech. Plan Check 0.0 hrs $0.00 j
Mech. Permit Fee: IMPERMIT
Other Mech. Insp. 0.0 hrs $45.00 rs P f
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary ,Sewer District, school
n: _:s ,..,. TL...... f;.,... ,. ., 6.....,d ,.., sb., ..... /:...:,.n...� :nFnn�nt:nn mrni /n610 and nro nn /v nn nctimnlo. Cnntart tho nOnt for addn't info_
FEE ITEMS (Fee Resolution 11 -053 hff 7,711?)
FEE
QTY /FEE
MISC ITEMS
PME Plan Check:
$0.00
PME Unit Fee:
$133.00
PME Permit Fee:
$45.00
Administrative Fee: IADMIN
$42.00
Work Without Permit? 0 Yes (F) No
$0.00
Travel Documentation Fee: ITRAVDOC
$45.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bld Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:'
$266.50
$0.00 TOTAL FEE:
$266.50
Revised: 10/01/2012
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014 -3255
Telephone: 408 - 777 -3228
Fax: 408 - 777 -3333
JOB ADDRESS: 2 Z -5-13 ,.x-pj2,j)G F f
PERMIT # 11 6�
OWNER'S NAME: 13 R uc /4 A t0
PHONE # 4 a
GENERAL CONTRACTOR: 6w r+z
BUSINESS LICENSE #
ADDRESS: f 4-e- V ✓n-v4 �4 1 Lw- II-D:
CITY /ZIPCODE: S 4.0
*Our municipal code requires all businesses working in the city 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 CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
ig ure Date
Please check applicable subcontractor d complete the following information:
1
Owner / Contractor Signature
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner / Contractor Signature
Date