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11040081 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10317 MIRA VISTA RD CONTRACTOR:VALLEY HEATING PERMIT NO: 11040081 &COOLING OWNER'S NAME: DAVID CLOUGH 1171 N 4 TH ST DATE ISSUED:04/12/2011 NER'S PHONE: 4082530626 SAN JOSE,CA 95112 PHONE NO:(408)294-6290 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F ELECT F PLUMB License Class &—o O Lic.# a�&,5'41 0 I r MECH r- f-RESIDENTIAL COMMERCIAL Contractor V� A G,,��,, Date ��—�1 JOB DESCRIPTION: REMOVE&REPLACE FURNACE 80%,70 K BTU IN I hereby affirm that I am licensed u er provisions of Chapter 9 EXISTING (commencing with Section 7000)of Divisia on 3 of the Business&Professions CLOSET 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. Sq.Ft Floor Area: Valuation:$2815 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 APN Number:35702039.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above informa on is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 0 PAYS 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 DAY OM LAST LED INS7/7,�,/' indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the Issued by Date 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. Z!/ ROOFS: Signature Date � All roofs shall be inspected prior to anyny 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: I 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) 1,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,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: 02 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 CONSTRUCTION LENDING AGENCY 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 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 in the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION .emnify 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 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: 10'bll �"t 11Z,4 VI STA PERMIT# OWNER'S NAME: AVV%ak% A *JDAV lb C,WLkGt PHONE# (W-o7S 3-'V` cv Xr GENERAL CONTRACTOR: U411t *6-,0 T1r1 o-OA6,J BUSINESS LICENSE# 07515'140 ADDRESS: //7/ • &17-# t CITY/ZIPCODE: 5C C4, 6-/1o7 *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. _ ,D I am not using any subcontractors: Signatu a Date Please check applicable subcontractors and comp ete the following information: s/ 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 actor Signature Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 35702039 . 00 DATE ISSUED. . . . . . . : 04/12/2011 RECEIPT # . . . . • • • . . : BS000013160 REFERENCE ID # . . . : 11040081 SITE ADDRESS . . . . . : 10317 MIRA VISTA RD SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER DAVID CLOUGH ADDRESS . . . . . . . . . . : 10317 MIRA VISTA RD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 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 ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 2, 815 . 00 1 . 00 0 . 00 1 . 00 0 .00 1BSEISMICR VALUATION 2, 815 . 00 0 .50 0 . 00 0 .50 0 . 00 1MFR=<100 UNITS 1 . 00 126 . 00 0 . 00 126 . 00 0 . 00 1MPERMITFE 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 211 . 50 0 . 00 211 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 211 .50 21894 --------------- TOTAL RECEIPT 211 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10317 Mira Vista DATE: 04/12/2011 REVIEWED BY: Bobs APN: BP#: "VALUATION: 1$2,815 "PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Du lex PENTAMATION FURN/AC USE: p PERMIT TYPE: WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Furnace, Forced-Air 1MFR=<100 1 # $126 TOTALS: $126.00 Mech.Plan Check 0.0 hrs $0.00 Mech.Permit Fee: 1MPERMIT Other Mech.Insp. 0.0 hrs $42.00 L.-J L--d NOTE: These -fees are based on the preliminary information available and are only an estimate. Contact the Dept for addh 7 in o. FEE ITEMS (Fee Resolution 09-051 E '. "1,'702 FEE QTY/FEE MISC ITEMS F7 PME Plan Check: $0.00 PME Unit Fee: $126.00 PME Permit Fee: $42.00 Work Without Permit? Yes E) No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item BldgStds Commission Fee: IBCBSC $1.00 SUBTOTALS: $211.50 $0.00 TOTAL FEE: 1 $211.50 Revised: 01/15/2011 GENERAL PERMIT APPLICATION MEI, COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE a CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333•buildino cDcupertino.org MISC CUPERTINO I ❑PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS 10,61-7 O/L 1-7 f A i^A 1�l 11�;I,n 'Rb� ',I^I APN# 35 1 O 2- 0,3q 3 -D(J OWNER NAME Anrnk 'SA w �/�l V�,` UOU11Q PHONE 40 RC,3- of paE-MAIL STREET ADDRESS 0 31 ( �`r a . 'tn 1 ITY,STATE C -T`nO n A 1 olG O 1 4 FAX CONTACT NAME ,+ 1�` �J PHONE 4O Y) M L4_//_a n0 I E-MAIL STREET ADDRESS 1 n I NA) '-T� �f�C. CITY,STATE,ZIP � /1A OS'V , 15((/1 FAX X1']4..8a 11 OWNER 11OWNER-BUILDER `�❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT 1-1ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER.* O LICENSE TYPE�U BUS.LIC# COMPANY NAME\'Ft\` �►` E-MAIL(1'1 l�?/�C�IIe N&+ CVM FAX LA Y STREET ADDRESS1 1 / T,1 1 CITY,STATE,ZIP a t PHONE A L 0-p (_tp� ARCHITECT/ENGINEER NAME H �T LICENSE NUMBER BUS.LIC 9 `( COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ;SE OF ❑ SFD or Duplex ❑ Multi-Family PROJECT IN WI,DLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ NO FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORK "Remoy e VAU 0. ()I-D 9 O K I rUa ,^`1j6_ TOTAL VALUATION: 1 S RECEIVEIBTC t k �a} ,r: w. ;£= 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 co have read the Djf,cliptIon of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buildin ctio autho epresentatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMEL INFO TION REQUIRED �QraBJCfJ5> Qi . N� x .W € « t pa:� t❑�a�5,'CA�LYD?ER�°`��`,�-i�w's as MEPMiscApp_2011.doc revised 03/16/11