13010031CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10192 PARK CIR WEST
CONTRACTOR: JIM'S AIR
PERMIT NO: 13010031
_
CONDITIONING
OWNER'S NAME: HO WALTER K AND GLORIA C
917 QUERCUS CT
DATE ISSUED: 01/032013
OWNER'S PHONE: 4087365900
SUNNYVALE, CA 94086
PHONE NO: (408)655-0491
11 LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL Ll COMMERCIAL
License Class C �q Lie. # 4¢1.1. /D _
APT. # 4 REPLACE (E) WALL FURNACE, SAME LOCATION
/
Contractob�5 h)t,' LDS!/4Nlt Date.
I hereby affirm that 1 am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 o 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 thisymnit is issued.
Sq. Ft Floor Area:
Valuation: $2000
I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 32632015.10192
Occupancy APe:
Section 3700 of the Labor Code, for theperforrnance 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
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws 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
180 DAYS FROM C D INSPECTION.
indemnify And keep harmless the City of Cupertino againstliabilities, judgments,
costs, and expenses which. may accme against said City in consequence of the
Issued by: Date; 3
granting of this permit, Additionally, the applicant understands and will comply
with all non -point u regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date t-_343
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 new materials for
inspection. -
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
1 hereby affirm that I am. exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" 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)
I, as -owner of the property; am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business& Professions: Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(a) should I 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 I
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 Health & Safety Code, s 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the perfonnanceof the work for which this
Owner or authorized agent: Date:
permit is issued.
-
1 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 tobecome subject to the Worker's
CONSTRUCTION LENDING AGENCY
Compensation laws of California. If, atter making this: certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
I 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.
work'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 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) we to save
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, andexpenses which may accrue-againstsaid City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non-poilergotace regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature .' Date f�
-
CUPERTINO
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 O 0 M'
(408) 777-3228 • FAX (408) 777-3333 • buildinG(a)cuoertino.oro �O�
❑PLUMBING ®MECHANICAL OFT FCIRICAL ❑MISCELLANEOUS
FROJECTADDRESS
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CONTACT NAME
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❑ OWNER ❑ owmm-BUIIDER ❑jJOWNE/RAAGEbIT ❑ camuCTOR 13 CONTRACTOR AGENT ClAitcmTwr ❑DIID1:113ENGt DEVELOPER TENANT
CONTRACTORNAME j! �Yl.r 41-1 �a/N�OItOkJ
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LICENSE 7YPE
BUS. LIC %
COMPANY NAME —T1 t.S f'fl/ /f (,(�••.1_.—k0 %EMAQ./'�^.,GG
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STREET ADDRESS , V �IV
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ARCH ECLFNGINEER NAME
LICENSE NUMBER
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COMPANYNA M
E-MAIL
FAX '
STREET ADDRESS
CITY. STATE, ZIP
PHONE
USE OF ❑sFDaDUPLEX [3MULTI-FAMLLY
BUDDING: ❑CONOMCiAL
MOIECrUMI DLWD ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECTIN ElYES
FLOOD ZONE ❑ NO
15 THE BLDG AN ❑YES
EICFI.ERNOMJET ❑ NO
DESC=ON OF WORK
amzve
TOTALVALUATION:
RECEIVED BY:
By my signature below, I certify to each of the following: I am the property owner or authorized ageut to act on the prop a's beh . I bave read thus
application and the information I have 'tied is correct 'I have read the Dwaiption of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to ] ' ns 'ze representatives of Cupertino to enter the above-idmUfied'property for inspection ptu�oses:
Signature ofApplicam/Ageut Date:
S LEMENTAL INFORMATION REQUIRED
OFFICE USE ONLY
V
OVER-THE-COUNTER
Y
❑ EXPRESS
V
U
❑ STANDARD
❑ LARGE
❑ MAJOR
AEPMrscApp_2011.doc revised 06121111
9 "TTV CC !"TT1D1V1DTTNl1
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.. These fees are based on the Prefindna in ormation available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eft. 7111121
\.111 Vl' VVl J:,l\111\V
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 1111%tPARK CIRCLE WEST #4 DATE: 01/03/2013 REVIEWED BY:
APN: BP#: 'VALUATION: $2,000
PERMIT TYPE: Mechanical Permit
I PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY Multi -Family Dwelling
USE:
B31Storo�es Yes No is
PERMIT TYPE: FURN/AC
WORK
REPLACE E WALL FURNACE SAME LOCATION
SCOPE
Mech. Permit Fee:
IMPERMTT
APPLIANCE / EQUIP TYPE
FEE ID
Other Mech. Insp. 0.0 hrs
QTY
UNITS
BP FEES
Other Elec, Insp.ED
Furnace, Gravity -Type
1MFR=<100
Plumb. hap. Fee.
1
#
$133
Consinection Tier:
Administrative Fee: /ADMIN
$42.00
Work Without Permit? 0 Yes O No
$0.00
Advanced Planning Fees.-
ees:Travel
TravelDocumentation Fee: ITRAVDOC
$45.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Feed 1BCBSC
$1.00
`,�xyat
TOTALS:
hx`
$0.001' OTyz
$266.50266.50
$133.00
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.. These fees are based on the Prefindna in ormation available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eft. 7111121
FEE
NONE'
ai"�`
Plan Check Fee:
Mech. Plan Check 0.0 hrs
$0.00
Plumb. Plan Check
Elec. Plan Check
Mech. Permit Fee:
IMPERMTT
Plumb. Permit Fee:
61,,c. Permit Fee:
Other Mech. Insp. 0.0 hrs
$45.00
Other Plumb Insp.El
Other Elec, Insp.ED
Ahxh. Insp.: Fee: I
Plumb. hap. Fee.
$133.00
Elec. Insp. Fee:
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.. These fees are based on the Prefindna in ormation available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eft. 7111121
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
SuppL PCI Re
PME. Plan Check:
$0.00
Peennu Fee:
Suppl.Insp Fee
PME Unit Fee:
$133.00
PME Permit Fee:
$45.00
Consinection Tier:
Administrative Fee: /ADMIN
$42.00
Work Without Permit? 0 Yes O No
$0.00
Advanced Planning Fees.-
ees:Travel
TravelDocumentation Fee: ITRAVDOC
$45.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Feed 1BCBSC
$1.00
`,�xyat
$
hx`
$0.001' OTyz
$266.50266.50
Revised: 10/01/2012
C: IJPERT/NO
Building Department
City Of Cupertino
10300 Torre Avenue
Fax: 408-777-3333
JOB ADDRESS: 16f%,!`-,' PERMIT #
OWNER'SNAME:.3' V Lie PHONE# Irb8- 625-e'I�/�
GENERAL CONTRACTOR: -: r+,A`S .-4F/ Ce s OhrK BUSINESS LICENSE #
ADDRESS: 9/ 0C -,e ;. `. CITY/ZIPCODE:
*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 SU EB TRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractorss.
Signature Date
Please check applicable subcontractors and complete the following information:
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