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11060137 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10226 VISTA DR CONTRACTOR __ PERMIT NO: 11060137 OWNER'S NAME: MONICA BACON U `Q(� j 6 DATE ISSUED:06/16/2011 c71�'NER'S PHONE: 4082095315rL PHONE NO: L LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT r- PLUMB License Class Lic.# �QJ Q .,"L MECH F_ RESIDENTIAL COMMERCIAL /�i6v Contractor ['U t�'Q[;GV 1)2. Date qC& C/ I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE&REPLACE FURNACE (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. n 5 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:$2800 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:31624018.00 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 DAYS FROM LAST 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 byk� —� Date: Signature �u (— U' �`^-- Date C �l 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. 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, Signature of Applicant: Date: Business&Professions Code) I,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. 1 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 permit is issued. 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 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 author ed agent: become subject to the Worker's Compensation provisions of the Labor Code,I mustti n 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 mik'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.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building 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, and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION <ig of this permit.Additionally,the applicant understands and will comply wi,a 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 CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 31624018. 00 DATE ISSUED. . . . . . . : 06/16/2011 RECEIPT #. . . . . . . . . : BS000013788 REFERENCE ID # . . . : 11060137 SITE ADDRESS . . . . . : 10226 VISTA DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER MONICA BACON ADDRESS 10226 VISTA DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : BOUDREAU PLUMBING & CONTRACTOR TBD - TO BE DETERMINED LIC # 00096 COMPANY TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 2, 800 .00 1. 00 0. 00 1 .00 0. 00 1BSEISMICR VALUATION 2, 800 . 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 #9332 --------------- 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 [IJADDRESS: 10226 vista dr. DATE: 06/16/2011 REVIEWED BY: bobs. PN: I BP#: 'VALUATION: 1$2,800 *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 F-01hrs $0.00 Mech.Permit Fee: IMPERMIT Other Mech.Insp. 0.0 hrs $42.00 Lj NOTE: These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'1 info. FEE ITEMS (Tee Resolution 09-051 Lff "Ll0) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $126.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes G No $0.00 Travel Documentation Fee: 1 TRA VDOC $42.00 Strori Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $211.501 $0.00 =TOTAL FEE: $211.50 Revised: 04/29/2011 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 CONTRACT,OR/ SUBCONTRACTOR LIST JOB ADDRESS: i PERMIT# -16 OWNER'S NAME: ,[ *(iA /� PHONE# GENERAL CONTRACTOR: 0 w-1 BUSINESS LICENSE# ADDRESS: &,s &J CITY/ZIPCODE: C *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 7:0FIUPEIRTINO BUSINESS LICENSE. I am not using any subcontractors: (" Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum /Wood Glass / Glazing ___�7ff'eatijg:) Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date GENERAL PERMIT APPLICATIONMEP COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION 10300 TORRE AVENUE- CUPERTINO, CA 95014-3255 (408)777-3228 • FAX(408)777-3333•buildingacupertino.org MISIC yUPERTIN0 PLUMBING bIECHAMCAL �CTRICAL ❑MISCELLANEOUS PROJECT ADDRESS 102-2fVsh� D LCv ,PN 2 0 17' OWNER NAME (C-A � ` , � O 2o!5^-f3 f J E MAII STREET ADDRESS l VV =,STATE,ZIP FAX CONTACT NAME PHONE E-MAI STREET ADDRESS CITY,STATE,ZIP FA-1C ❑OWNER ❑ OwNER-BUILDER ❑ OWNER AGENT 13CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER C] DEVELOPER ❑TENANT CONTRACTOR NAME fu L /n0 v D /,, L cM /I LICENSE TYPE BUS.LIC 9 COMPANY NAME �V�i7/} /y, y � .�.►y!D/JG� ( �/JE-MAIL FAX STREET ADDRESS Y�8 / '�',v A , C1TY.STATE zIl' °N(p.�V 3�G ARCHIIECTIENG NEER NAME �/ ,\ LICENSE NUMBER BUS.LIC A COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE z of SFD or Duplex ❑ Multi-Family PROJECT IN WR.DLAND PROJECT IN ,,gUCTURE; ❑ Commercial URBAN �p�FA�Cp� ❑ Yes n �❑� No FLOODz-oNE ❑ Yes ❑ No DESCRIPTION OF WORK OV -.J �,kA 6'� ' VC�C✓ ( / �1 TOTAL.VALUATION: 0)0 By my signature below,I certify to each of the following: I am the property owner or authorized agent to act an the property owner's behalf. I have read this application and the information I have provided is correct I have read the Description of Work and verify it is accurate. I agree comply with all applicable local ordinances and state laws relating to b ilding co ction. I a{u�tho�rizze�representatives of Cupertino to enter the abo e-' enge %for inspection purposes. Signature of Applicant(Agent � L 1) C�C.�F�L/ Date: ((11 SUPPLEIv>ENTAL INFORMATION REQUIRED NjEFMisa4pp-2011.doc revised 03/16/11