11100190I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 10182 BILICH PL I CONTRACTOR: VALLEY HEATING & I PERMIT NO: 11100190
OWNER'S NAME: HANSEN ANN E AND BYRON J 11171 N 4 TH ST I DATE ISSUED: 10/27/2011 1
O"-''ER'S PHONE: 4082578899
Q LICENSED CONTRACTOR'S DECLARATION
License Class L Lic. # c n , 4 O
Contractor _ � I�1 �(�l,�C:*te L
1 hereby affirm that I am licensed 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.
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 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 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.
Date
OWNER -BUILDER DECLARATION
I hereby affirm that I 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 (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 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.
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
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
I certify that 1 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 liabilities, judgments,
C :rid expenses which may accrue against said City in consequence of the
g.. ag 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
SAN JOSE, CA 95112
PHONE NO: (408)294-6290
BUILDING PERMIT INFO: BLDG ELECT PLUMB
MECH f— RESIDENTIAL COMMERCIAL
JOB DESCRIPTION: REPLACE FURNACE AT EXISTING LOCATION
Sq. Ft Floor Area: I Valuation: $3629
APN Number: 31621066.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: 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 new materials for
inspection.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I 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 I 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 I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or aut ent:
Date: 10-2-7-)
(t)QNSrRUCTION LENDING AGENCY
I hereby affirm 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
1 understand my plans shall be used as public records.
Licensed Professional
6 ITEMS OF 6
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 31621066.00
DATE ISSUED.......: 10/27/2011
RECEIPT #......... BS000015168
REFERENCE ID # ...: 11100190
SITE ADDRESS 10182 BILICH PL
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......
OPERATOR: suew
COPY # : 1
OWNER HANSEN ANN E AND BYRON J
ADDRESS ..........
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-2326
RECEIVED FROM ....: VALLEY HEATING
CONTRACTOR ATKINSON, THOMAS LIC # 141
COMPANY VALLEY HEATING & COOLING
ADDRESS 1171 N 4 TH ST
CITY/STATE/ZIP ...: SAN JOSE, CA 95112
TELEPHONE (408)294-6290
FEE ID
UNIT
QUANTITY
AMOUNT
PD -TO -DT
THIS REC
-------
NEW BAL
----------
-ADMIN
-------------
HOURS
----------
1.00
----------
41.00
----------
0.00
41.00
0.00
1BCBSC
VALUATION
3,629.00
1.00
0.00
1.00
0.00
1BSEISMICR
VALUATION
3,629.00
0.50
0.00
0.50
0.00
1MFR=<100
UNITS
1.00
130.00
0.00
130.00
0.00
1MPERMITFE
FLAT RATE
1.00
44.00
0.00
44.00
0.00
1TRAVDOC
FLAT RATE
1.00
44.00
0.00
44.00
----------
0.00
----------
TOTAL PERMIT
----------
260.50
----------
0.00
260.50
0.00
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT :
AMOUNT
---------------
260.50
---------------
260.50
VOICE ID DESCRIPTION
-------- ----------------------------
505 FINAL ELECTRICAL
508 FINAL MECHANICAL
REFERENCE NUMBER
--------------------
22782
VOICE ID DESCRIPTION
-------- ----------------------------
507 FINAL PLUMBING
Simplified Prescriptive Certificate of Compliance: 2008 Residential HVAC Alterations CF -IR -ALT -HVAC
Climate Zones 1 and 3 - 7
Site Address: 10182
18 2 B i l i C h Place
IConditioned
Enforcement Agency:
Date:
Permit #:
Duct insulation
Equipment Ty el
List Minimum Efficiency 2
Floor Area
requirement
Thermostat
®x
Packaged Unit
Furnace
AFUE800�a
COP ----Served
Served by system
Over 40 ft of ducts
added or replaced in
JE
Indoor Coil
Condensing Unit
SEER_ _Ej
❑ EER — —
HSPF
El Resistance
2400(Ifnot
----- sf
unconditioned space
already present, must be
installed)
Other
I. Equipment Type: Choose the equipment being installed; if more than one system, use another CF -IR -ALT -HVAC for each system.
2. M inim um Equipment Efficiencies: 13 SEER, 78% AFUE, 7.7HSPF for typical residential systems.
Contractor (Documentation Author's /Responsible Designer's Declaratiop Statement)
• I certify that this Certificate of Compliance documentation is accurate and complete.
• I am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the design identified on this
Certificate of Compliance.
• I certify that the energy features and performance specifications for the design identified on this Certificate of Compliance conform to the
requirements of Title 24, Parts 1 and 6 of the California Code of Regulations.
• The design features identified on this Certificate of Compliance are consistent with the information documented on other applicable
compliance forms, worksheets, calculations, plans and specifications submitted to the enforcement agency for approval with the permit
application.
Name:
Signature:
Company: Valley Heating and Cooling
Date:
Address: 1171 N 4Th Street
License: 258540
City/State/Zip:san ,Jose ,Ca 95112
Phone:408-294-6290
BY-.
2008 Residential Compliance Forms March 2010
FOR -07
CITY OF CUPERTINO
i FFF. FQTIMATnR - RITTI,DING DIVISION
imlADDRESS:
10182 bilich pl.
QTY/FEE
DATE: 10/27/2011
REVIEWED BY: bobs.
BP FEES
APN: & a
BP#:
III X15 �
"VALUATION: 1$3,629
*PERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Du lex
USE: p
PENTAMATION FURN/AC
PERMIT TYPE:
WORK
re lace furnace at existing location.
SCOPE
PME Unit Fee:
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Furnace, Forced -Air
1MFR=<100
1
#
$130
PME Unit Fee:
$130.00
PME Permit Fee:
$44.00
7_
Administrative Fee: ]ADMIN
$41.00
Work Without Permit? 0 Yes 0 No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
1 $130.00
Strong Motion Fee: IBSEISMICR
Mech. Plan Check 0.0 hrs $0.00 -
Mech. Permit Fee: IMPERMIT -
Other Mech. Insp. 0.0 1 hrs $44.00
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District,, School
iiicfrinf ofn 1 Th.— f— Oro hncod nn fho nrot/nfH"mV infarm"finn OVOilOhio ""d OPO anhl On octimaiO_ f'Ontart tho Dont far addn'1 info.
FEE ITEMS (Eee Resolution 11-053 L f'.' 7.11;"11)
FEE
QTY/FEE
MISC ITEMS
PME Plan Check:
$0.00
PME Unit Fee:
$130.00
PME Permit Fee:
$44.00
Administrative Fee: ]ADMIN
$41.00
Work Without Permit? 0 Yes 0 No
$0.00
Travel Documentation Fee: ITRA VDOC
$44.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$260.50
$0.00 TOTAL FEE:
$260.50
Revised: 10/01/2011
CUPERTINO
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION , Gj
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 V j
408 777-3228 • FAX (408) 777-3333 • building(d�cupertino.org 1 "
() i ► misc
❑PLUMBING EtNECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROTECT ADDRESSD 1. Q a I (I c ^ n L,
AFN #
OWNERNAME n 1^
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PHONE a ��
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iWNERAGENT
CITY, STATE, ZIP 5A(,t /j SU
FAX
❑ OWNER ❑ OWNER -BUILDER ❑SOY
ACONTRACCOR ❑ CON7RACI'ORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME , f (I n„ +I T / „� I
v t T ((J
LICENSE NUMBER �I 1 O
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LICENSE TYPE �+
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BUS. LIC # I
COMPANY NAME (f %
E-MAIL
FAX
STREET ADDRESS I I N ��Q
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ARCHITECT/ENOWEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAIL
E-MAIL,
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
JSE OF SFD or DUPLEX ❑ MULTI -FAMILY
BUILDING: ❑ COMMERCIAL
PROIECT IN WILDLAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROIECT IN ❑ YES
FLOOD ZONE ❑ NO
IS THE BLDG AN ❑ YES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK 1/1 V LkI I vcA-hV y
TOTAL VALUATION:
RECEIVED BY: L:�16_j
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct j have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above -identified property for inspection pu@oses.
Signature of ApplicantlAgentr Date:
SUPPLEMENT ORMATION REQUIRED
OFFICE USE ONLY
a
Y
U
T
U
e,
❑ OVER-THE-COUNTER
❑ EXPRESS
❑ STANDARD
❑ LARGE
❑ MAJOR
MEPMtscApp 2011.doc revised 06121111
I
.UPERTINO
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: i Lh L
PERMIT #
OWNER' S NAME: ✓1 �1 S -, r'1
PHONE # �( � - , 5 7 - ?8�7
GENERAL CONTRACTOR:
BUSINESS LICENSE # S�S�iD
ADDRESS: /J:Z/ /\l • 4-h
CITY/ZIPCODE: '1 6jY 154 15/wZ
*Our municipal code requires all businesses working in the city to have a utty of t_;upertirM ausIness ncense.
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:
na re Date
Please check applicable subcontractors and comp ete 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