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09120140 CITY OF CUPERTITIO BUILDING PERMIT BUILDING ADDRESS: 22165 VIA CAMINO CT CONTRACTOR:VALLEY HEATING& PERMIT NO:09120140 COOLING OWNER'S NAME: FULLER LYNN M 1171 N 4 TH ST DATE ISSUED: 12/23/2009 ,'NER'S PHONE: 4084810878 SAN JOSE,CA 95112 PHONE NO:(408)294-6290 19, LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL License Class "�/� Lic.# Z �s' y REPLACE FURNACE AND ADD A/C UNIT Contractor � �/fir/�,i/Y1'77'� Date lL 7�J:�OZ I hereby affirm that 1 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. 1 hereby affirm under penalty of perjury one of the following two declarations: 1 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:$7500 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:3264601 1.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that 1 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 byy' _/ :— Dater with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. /Z Z� anyRE- Signature Date All roofs shall be inspected prior to any roofing material being installed.if a roof is installed without first obtaining an inspection,1 agree to remove all new materials for inspection. OWNER-BUILDER DECLARATION Signature of Applicant: Date: 1 hereby affirm that 1 am exempt from the Contractor's License Law for one 01 the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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) I,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 25.505,25533,and 25534. 1 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 1 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 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 permit is issued. Owner or authorized agent: Date: 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the labor Code,I mus 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. 1 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 ......n the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION ,unify and keep harmless the City of Cupertino against liabilities,judgments, ,ts,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 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 -.UPEkTINO Building Department JOB ADDRESS: PERMIT # Z Z-1/ (/ice ���.:a � -/-- © e-� 2-�I't 0 OWNER'S NAME: PHONE # GENERAL CONTRACTOR: `�� FAX # I am not using any subcontractors: 911 a t dre Date Please check applicable subcontractors d com:)lete the following information: 21 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 er/ tr ctor Signature Date CITY OF CUPERTINO FURNACEAC CUPEkTINO PERMIT APPLICATION FORM r 2 ? I� APN# , A-1 Cf C) I ` •CID Date: Building Address: Owner's Name: Phone#: LJ Contractor: Phone#: ��- co Fax#: Contractor License#: V17 Cupertino Business License#: Con act: Phone#: Fax#: Building Permit Info: Elect � Plumb Mech Residential Commercial ❑ Job Description: v` For Resi ential Installations: Attic ❑ 1St floor [ 2n6 floor ❑ Adhere to minimum setback requirement NK 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): 75, a `o 17 Strapped ❑ On Platform ❑ Bonc ed ❑ New Location ❑ Replacement Valuation: Green Building: Must attach Green Building Check list to this application CITY OF CUPERTINO FURVACE/AC OF CUPERTINO FEE SCHEDULE Quantity Fee ID Fee Descrip>ion Fee Permit Type Group FURNACE FURN/AC 1 MCRAA Commercial-I:epair/Alteration/Add to M ea heating appliance,refrigeration unit, cooling unit,a:)sorption unit,or ea heating,coolir.g,absorption or evaporative cooling system,incl installation of controls regulated by this code. 1MCREPALT Commercial fir the repair of alt/add to M ea heating appliance,refrigeration unit,cooling unit,VAV boxes, absorption unit or ea heathing, cooling absorption,or evaporative cooling sys, incl install of controls regulated by this code. 1MCSUSHTR Commercial Iastall/Relocate ea M suspended heater,recessed wall htr, or floor mounter unit heater. lPGASCOM Commerical fir ea gas piping System P 1-4 outlets 1BPGAS For each gas piping system of 5 or P more per outlot. 1MCAPPVNT Commercial fir the install/relocate/ or M replacement c f ea appliance vent installed &rict incl in an appliance permit. 1BSEISMIC0 Commercial E,eismic B 1NIRRAA Residential R,,-pair/Alteration/Add to M ea heating appliance,refrigeration unit, cooling unit,a3sorption unit,or ea heating,coolirg,absorption or evaporative cooling system,incl installation of controls regulated by this code. 1MRSUSHTR Residential Install/Relocate ea M suspended heater,recessed wall htr, or floor mounter unit heater. lMRAPPVNT Residential for the install/relocate/or M replacement c f ea appliance vent install &not incl in an appl permit. CITY OF' CUPERTINO FURNACE/AC CUPEkTINO FEE S CHEDULE Quantity Fee ID Fee Description Fee Permit Type Group AIR FURN/AC _CONDITIONING 1BCAIRHAN Commercial,VC Units<= 10k CFM B 1MCRAA Commercial Mech Repair/alt/add M 1BSEISMICO Seismic Commercial B 1PGASCOM Commerical ibr ea gas piping System P 1-4 outlets 1PGASRES Residential fir ea gas piping system P of 1-4 Outlet, 1BPGAS For each gas piping system of 5 or P more per outl A. Comm/Resid 1BRENLAIRHAN Residential A/C units <= IOk CFM B 1MRRAA Residential 1v[ech Repair/alt/add M 1BSEISMICR Seismic Residential B 1 EPERMITFEE Electric Perm it E 1MPERMITFEE Mechanical Fermit M 1PPERMITFEE Plumbing Pei mit P 1 TRA VDOC Travel Docur lentation B 1BUSLIC Business Licfsnse B