09100192CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19370 CALLE DE BARCELONA
CONTRACTOR: AIR QUALITY HEATING &
PERMIT NO: 09100192
AIR
O"JNER'S NAME: DAVID DIKERSON
720 NORTHRUP ST
DATE ISSUED: 10/28/2009
1, .. AER'S PHONE: 4087571733
SAN JOSE, CA 95126
PHONE NO: (408)293-7138
Or, LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class�t ^ Lic. #
MECH RESIDENTIAL COMMERCIAL
Contractor Date
JOB DESCRIPTION: REPLACE FURNACE
I hereby affirm that am licensed under the provisions f 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
Sq. Ft Floor Area:
Valuation: $4200
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
1 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
APN Number: 37505010.00
Occupancy Type:
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 LAST CALLED INSPECTION.
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
Issued by;_� - Date:
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
RE -ROOFS:
rr
Si -nature Date 7 V�
All roofs shall be inspected prior to any roofing material being installed. If a roof is
❑ OWNER -BUILDER DECLARATION
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
Signature of Applicant: Date:
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)
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1, as owner of the property, am exclusively contracting with licensed contractors to
constrict the project (Sec.7044, Business & Professions Code).
HAZARDOUS MATERIALS DISCLOSURE
I hereby affirm under penalty of perjury one of the following three
I have read the hazardous materials requirements under Chapter 6.95 of the
declarations:
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
I have and will maintain a Certificate of Consent to self -insure for Worker's
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Compensation, as provided for by Section 3700 of the Labor Code, for the
Safety Code, Section 25532(a) should I store or handle hazardous material.
performance of the work for which this permit is issued.
Additionally, should 1 use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
I have and will maintain Worker's Compensation Insurance, as provided for by
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Section 3700 of the Labor Code, for the performance of the work for which this
Health & Safety Code, Sections 25505, 25533, and 25534.
permit is issued.
1 certify that in the performance of the work for which this permit is issued, I shall
Owr auth r' d". ut:
n r
Z G9
not employ any person in any manner so as to become subject to the Worker's
Date:IV
4444
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
CONSTRUCTION LENDING AGENCY
forthwith comply with such provisions or this permit shall be deemed revoked.
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.)
APPLICANT CERTIFICATION
Lender's Name
1 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
Lender's Address
to building construction, and hereby authorize representatives of this city to enter
the above mentioned property for inspection purposes. (We) agree to save
ARCHITECT'S DECLARATION
mify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said 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 -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
7 ITEMS OF 7
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 37505010.00
DATE ISSUED.......: 10/28/2009
RECEIPT #.........: BS000009057
REFERENCE ID # ...: 09100192
SITE ADDRESS .....: 19370 CALLE DE BARCELONA
SUBDIVISION ......
CITY .............. CUPERTINO
IMPACT AREA ......
OWNER ............: DAVID DIKERSON
ADDRESS ..........: 19370 CALLE DE BARCELONA
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
OPERATOR: patg
COPY # : 1
RECEIVED FROM ....: MATTHEW T FARBER
CONTRACTOR .......: MATTHEW FARBER LIC # 22791
COMPANY ..........: AIR QUALITY HEATING & AIR
ADDRESS ..........: 720 NORTHRUP ST
CITY/STATE/ZIP ...: SAN JOSE, CA 95126
TELEPHONE ........: (408)293-7138
FEE ID
UNIT
QUANTITY
AMOUNT
PD -TO -DT
THIS REC
NEW BAL
----------
1BCBSC
-------------
VALUATION
----------
4,200.00
----------
1.00
----------
0.00
----------
1.00
----------
0.00
1BSEISMICR
VALUATION
4,200.00
0.50
0.00
0.50
0.00
1EPERMITFE
FLAT RATE
1.00
42.00
0.00
42.00
0.00
1MPERMITFE
FLAT RATE
1.00
42.00
0.00
42.00
0.00
1MRRAA
UNITS
1.00
63.00
0.00
63.00
0.00
1PPERMITFE
FLAT RATE
1.00
42.00
0.00
42.00
0.00
1TRAVDOC
FLAT RATE
1.00
42.00
0.00
42.00
0.00
TOTAL PERMIT
----------
232.50
----------
0.00
----------
232.50
----------
0.00
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT :
AMOUNT
---------------
232.50
---------------
232.50
VOICE ID DESCRIPTION
-------- ----------------------------
505 FINAL ELECTRICAL
508 FINAL MECHANICAL
REFERENCE NUMBER
--------------------
MC
VOICE ID DESCRIPTION
-------- ----------------------------
507 FINAL PLUMBING
CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN # � � � 7 � , U �
�
Date:
Building Address 13-37� C&&
l
Owner'
N
Phone #: qV
Contractor:
Phone #:
6 ' zg� WC6
Vim'" ti
Fax #:
Contractor License #:
Cupertino Business License #:
X61
-
Contact:ko—
Phone #: G S- 7 33
Fax #:
Building Permit Info:
Elect 0 1 Plumb Mech-M-
Residential Commercial ❑
Job Description: �� A
For Residential Install ons:
Attic ❑ 1 st floor ❑ 2"d floor ❑
Adhere to minimum setback requirement ❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction (Usage Class):
LfLb� U 0
Strapped ❑ On Platform ❑ Bonded New Location 0 Replacement
Project Size: Express [7 --Standard ❑ Large ❑ Major ❑
Valuation:
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index.
Revised 01/07/09
CITY OF
CUPEkTINO
CITY OF CUPERTINO
FURNACE/AC
FEE SCHEDULE
Quantity
Fee ID
Fee Description
Fee
Permit Type
Group
1MRAPPVNT
Residential for the install/relocate/ or
M
replacement of ea appliance vent
install & not incl in an appl permit.
FURNACE
FURN/AC
1 PGASRES
Residential for ea gas piping system of
P
1-4 Outlets
1 BPGAS
For each gas piping system of 5 or
P
more per outlet.
1 BCBSC
Cal Bldg Standards Commission Fee
B
ALL PERMIT
TYPES
1BSEISMICR
Residential Seismic
B
1 MECPLNCK
Mechanical Plan Check
M
1MFR=<100
Furnace Syst <=100k BTU install or
M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance up to and
include 100,000 Btu/h
1 MFRN> 100
Furnace Syst > l 00k BTU install or
M
relocate ea forced-air/gravity type
furnace/bumer, incl ducts/vents
attached to such appliance over
100,000 Btu/h
'
1 EPERMITFEE
Electric Permit Fee
E
1MPERMITFEE
Mechanical Permit Fee
M
1PPERMITFEE
Plumbing Permit
P
j
I
1TRAVDOC
Travel Documentation
B
1 BUSLIC
Business License
B
1. use LOWN6NM P4 t
2. Use Low VOC, Water -Based Wood Finishes
3. Use LovlrNo VOC Adho'
4. Use Salvaged Materials for Interior Finishes
5. Use Engineered Sheet Goods with no added Urea
Formaldehyde
6. Use Exterior Grade Plywood for Interior Uses
7. Seal �II:a91 P.ele�boa�st 4r,F
8. Use FSC Certified Materials for Interior Finish
9. Use Finger -Jointed or Recycled -Content Trim
10. Install Whole House Vacuum System
N. Flooring
1. Select FSC Certified Wood Flooring
2. Use Rapidly Renewable Flooring Materials
3. Use Recycled Content Ceramic Tiles
4. Install Natural Linoleum in Place of Vinyl
5. Use Exposed Concrete as Finished Floor
6. Install Recycled Content Carpet with Low VOCs
Total Points Available:
Total Points Project Received:
1 IAQ/Health pts
y=yes
21AQ/Health pts
y=yes
31AQ/Health pts
y=yes
3 Resource pts
y=yes
61AQ/Health pts
y=yes
1 IAQ/Health pts
y=yes
41AQ/Health pts
y=yes
4 Resource pts
y=yes
1 Resource pts
y=yes
3 IAQ/Health pts
y=yes
8 Resource pts
y=yes
4 Resource pts
y=yes
4 Resource pts
y=yes
5 IAQ/Health pts
y=yes
4 Resource pts
y=yes
4 Resource pts
y=yes
1401 130 57
01 01 0
f�
o (09
G:data/progs/greenbuildngguidelines/remodelers/greenpointsfinal212.04protected.xis
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
WZ P-1
PERMIT-�D
OWNER'S AME:
PHONE # Cf- 17 3-3
GENERAL CONTRACTOR:
FAX #
J
I am not using any subcontractors: 1/14
Signature Dat
P1PaSP rhPck annlicable subcontractors an comvlete the followin: 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
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/ Contractor Signature
Date