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09120004 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21962 LINDY LN CONTRACTOR:AIR QUALITY HEATING& PERMIT NO:09120004 NIR T' NER'S NAME: MOORE JAMES A AND SUSAN M ''20 NORTHRUP ST DATE ISSUED: 12/01/2009 OWNER'S PHONE: 4082534574 'IAN JOSE,CA 95126 PHONE NO:(408)293-7138 LICEEN'S�ED CONTRACTOR'S DECLARATION 13UILDING PERMIT INFO: BLDG ELECT r- PLUMB License Class c IN Lic.# � MECH I— RESIDENTIAL COMMERCIAL ContractorD ate Ic [OB DESCRIPTION:REPLACE FURNACE GZffI hereby affirm that I am licensed u der 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. 3q.Ft Floor Area: Valuation:$3000 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 permit is issued. APN Number:35624012.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct.1 agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 D YS FROM ST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply 1 �4 q with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: / V / Date: 9.18. ff (� S* Jure Date—L111 1 I RE-ROOFS: ❑ OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this 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 permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. 1 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 Owner rized agent: Date: 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. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) 1 certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address he above mentioned property for inspection purposes.(We)agree to save L ..nify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date CITY OF CUPERTINO FUR-NACE/AC CUPEkTINO PERMIT APPLICATION FORM APN # Date: Building Address: 21 Z L rN Owner's Name: Phone#: Contractor: Phone#: Ef D r-2-q3 --7(3e Fax#: Contractor License#: Cupertino Business License#: 161 v� Contact: Phone#: (gyp T —Z-1 3— 7 I-TV MM _ Fax#: Building Permit Info: Elect ❑ Plumb ❑ Mech Residential �r Comme cial ❑ Job Description: For Residential Installations: Attic F1 I" floor�r 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): Strapped ❑ On Platform ❑ Bonded New Location El Replacement Project Size: Express ❑ Standard ❑ Large Major❑ Valuation: 3000� Green Building: Please complete relevant portio'.1 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 CUPERTINO alau".1 FURNACE/AC CUPEkTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group FURNACE FURN/AC 1 MCRAA Commercial-Relrair/Alteration/Add to M ea heating appliznce,refrigeration unit, cooling unit,absorption unit,or ea heating,cooling,,Lb sorption or evaporative cooling system,incl installation of ccntrols regulated by this code. 1 MCREPALT Commercial for :he repair of alt/add to M ea heating appliznce,refrigeration unit,cooling unit,VAV boxes, absorption unit cr ea heathing, cooling absorption,or evaporative cooling sys, incl install of controls regulated by this code. 1MCSUSHTR Commercial Install/Relocate ea M suspended heater,recessed wall htr, or floor mounted unit heater. 1PGASCOM Commerical for -,a gas piping System P 1-4 outlets 1BPGAS For each gas pip ng system of 5 or P more per outlet. 1MCAPPVNT Commercial for :he install/relocate/ or M replacement of ea appliance vent installed & not ijicl in an appliance permit. 1BCBSC Cal Bldg Standa-ds Commission Fee B ALL PERMIT TYPES 1BSEISMICO Commercial Seismic B 1 MRRAA Residential RepE.ir/Alteration/Add to M ea heating appliznce,refrigeration unit, cooling unit,absorption unit,or ea heating,cooling,,Lb sorption or evaporative cooling system,incl installation of ccntrols regulated by this code. 1MRSUSHTR Residential Install/Relocate ea M suspended heater,recessed wall htr, or floor mounted wait heater. CITY OF CUPERTINO FURNACE/AC CITYCUPEt�TINO FEE S(�HEDULE 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 1PGASRES Residential for ea gas piping system of P 1-4 Outlets 1BPGAS For each gas piping system of 5 or P more per outle-.. 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT J TYPES l 1BSEISMICR Residential Seismic B 1 MECPLNCK Mechanical PI in 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 1MFRN>100 Furnace Syst 100k BTU install or M relocate ea forced-air/gravity type furnace/bume:-, incl ducts/vents attached to sui;h appliance over 100,000 Btu/h 1 EPERMITFEE Electric Perm]t Fee E 1 MPERMITFEE Mechanical P,;rmit Fee M 1PPERMITFEE Plumbing Per-nit P 1 TRAVDOC Travel Documentation B 1BUSLIC Business License B