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11090025 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22014 BAXLEY CT CONTRACTOR:CONDITIONED AIR PERMIT NO: 11090025 OWNER'S NAME: KUSCHILL MELVIN AND MARIA 1701 LITTLE ORCHARD ST DATE ISSUED:09/06/2011 t' "ER'S PHONE: 4082570308 SAN JOSE,CA 95125 PHONE NO:(408)291-2220 LICENSED CONTRACTOR'S DECLARATIONr BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class C- Zu Lic.# 4(c-(Y1,6-?_ MECH F_ RESIDENTIAL r COMMERCIAL Contractor ��Lj �a'�t.t �+ &IDate 6 ZOff I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE&REPLACE FURNACE(SAME BTU)&ADD A/C (commencing with Section 7000)of Division 3 of the Business&Professions **SEE NOTES** 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 Sq.Ft Floor Area: Valuation:$8650 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:35606033.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 D A YS FROM T CALLED INSPECTION. 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. Issued by: /.yam-►-- �/ Date: 5; Signature Date OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two 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: Date: Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: 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 Health&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& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the 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 Code,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 Owner or Guth en p, become subject to the Worker's Compensation provisions of the Labor Code,I must , Date: forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of Aork'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 C.) corr;ct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to b#)Iding 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, r and expenses which may accrue against said City in consequence of the ig of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION w....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 CITY OF C UPERTINO aTyf FURNACE/AC CUPEkTINO PERMIT APPLICATION FORM APN # U 0 0_35 t [ ui l :a� lding Address: q Owner's Name: =#: ©3 9 Contractor: Phone #: , ( 4c�3� Z41 zZZo Coy\&t�� 1�r SSou�i-P S Fax #: CgCS ) 2-Cl i LZZ �I Contractor License#: Cupertino Business License#: G2 Contact: Phone #: SSE Fax #: Building Permit Info: Elect ❑ Plumb ❑ Mech Job Description: Residential Commercial For Residential Installations: Attic ❑ 1 S` floor 2nd floor ❑ Adhere to minimum setback re uirement ❑ For Commercial Installations: Replacement same weight ❑' Additional weight (structural talcs) ❑ Structural Calculations required for new installation ❑ New installation Planning Approval Required ❑ Cost of Project- Type of Construction (usage Class): Pk v n C C 2 c Strapped On Platform Bonded New Location Replacement Valuation: (8 5C) - © c> Green Building: Must attach Green Building Check list to this application CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION [tADDRESS: 22014 Baxley ct DATE: 09/06/2011 REVIEWED BY: larry s PN: BP#: "VALUATION: 1$8,650 PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Du lex PENTAMATION FURN/AC USE: p PERMIT TYPE: WORK remove and replace furnace same btu add a/c SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES A/C Units (<=10K cfm) 1BREMAIR 1 # $65 Furnace, Forced-Air 1MFR=<100 1 # $130 TOTALS: $195.00 Mech.Plan Check "00 $0.00 Mech.Permit Fee: IMPERMIT I F Other Mech.Insp. Fo.0 hrs $44.00 LLJ Lj NOTE: These ees are based on the preliminary in ormation available and are only an estimate. Contact the Dept-for addh 7 info. FEE ITEMS (Fee Resolution 1.1-053 F_:ff' 1.-"11) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $195.00 PME Permit Fee: $44.00 F-1 Work Without Permit? 0 Yes E) No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 A Stroh Motion Fee: IBSEISMICR $0.87 Select Administrative Item nnr Bld€7 Stds Commission Fee: IBCBSC $1.00 1 SUBTOTALS: $284.87 $0.00 TOTAL .T $284.87 Revised: 07/04/2041