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11010057I CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21865 EATON PL I CONDITIONING AAA FURNACE & AIR I PERMIT NO: 11010057 I OWNER'S NAME: SCOTT RUSSELL 1712 STONE AVE DATE ISSUED: 01/10/2011 'ER'S PHONE: 4082572126 1 SAN JOSE, CA 95125 I PHONE NO: (408)2934717 I ❑ LICENSED CONTRACTOR'S DECLARATION License Class�'`C 1x- Lic. # � 6 tS %f Contractor,40k k I'"Gl rA✓R Date I hereby affirm that I 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. 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 Section 3700 of the Labor Code, for the performance of the work for which s permit is issued. 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 upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which accrue against said City in consequence of the granting of this pe d tionally, the applicant understands and will comply with all non -point ou egulations per the Cupertino Municipal Code, Section 9.18. 1 Date /41 — 4' / tr OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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 Section 3700 of the Labor Code, for the performance of the work for which this 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 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. 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 upon the above mentioned property for inspection purposes. (We) agree to save •mnify and keep harmless the City of Cupertino against liabilities, judgments, , and expenses which may accrue against said City in consequence of the 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. Signature Date BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r MECH r RESIDENTIAL r COMMERCIAL I— JOB DESCRIPTION: REMOVE EXISTING FURNACE & REPLACE IN SAME LOCATION, WITH NEW Sq. Ft Floor Area: I Valuation: $3958 APN Number: 32619131.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued RE -ROOFS: 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 inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants asdef ed by the Bay Area Air Quality Management District I will rntain li c with the Cupertino Municipal Code, Chapter 9.12 and the Hea Safe de, Sections 25505, 25533, and 25534. agent: 7-1�SA_ Date: 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.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CITY OF CUPERTINO 5 ITEMS OF 25 PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 32619131.00 DATE ISSUED.......: 01/10/2011 RECEIPT #.........: BS000012441 REFERENCE ID # ...: 11010057 SITE ADDRESS .....: 21865 EATON PL SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OWNER SCOTT RUSSELL ADDRESS 21865 EATON PL CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM RANDO AAA HVAC,INIC CONTRACTOR RANDO, JIM LIC # 8050 COMPANY AAA FURNACE & AIR CONDITIONING ADDRESS 1712 STONE AVE CITY/STATE/ZIP SAN JOSE, CA 95125 TELEPHONE (408)293-4717 FEE ID UNIT QUANTITY AMOUNT --------- PD -TO -DT THIS REC NEW BAL ----------- 1BCBSC ------------- VALUATION ---------- 3,958.00 ---------- 1.00 0.00 1.00 0.00 1BSEISMICR VALUATION 3,958.00 0.50 0.00 0.50 0.00 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 42_ 00 0_00 1TRAVDOC FLAT RATE 1.00 42.00 0.00 ----- ------ TOTAL PERMIT 211.50 0.00 211.50 0.00 VOICE ID DESCRIPTION VOICE -------- ID DESCRIPTION -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS:( IPS- eq 4o)j PL PERMIT # t v 1 vv 72 OWNER'S NAME: S �, o -t , 1Z t&s5 G LL PHONE # O fr - 9 $ 7 " a 1 c9 (. GENERAL CONTRACTOR: Ap� BUSINESS LICENSE # ADDRESS: Z S AVG CITY/ZIPCODE: $on Ok 9S " *Our municipal code requires all businesses working in ttie city to nave a Baty of Luperiinu uuNuiv—...c 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. I am not using any subcontractors: Signature Please check applicable subcontractors and complete the following information: Date Owner / Contractor —7—/0 Date 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 / Contractor —7—/0 Date CITY OF CUPERTINO FF F F QT>I X4 A TnR — RT ITT .DING DIVISION APPLIANCE / EQUIP TYPE ADDRESS: 21865 eaton place DATE: 01/10/2011 REVIEWED BY: bobs. UNITS APN: BP#: *VALUATION: $3,958 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex $126 PENTAMATION FURN/AC PERMIT TYPE: USE: rS11ppl. I isp I -'c e WORK replace existing furnace at same location PME Unit Fee: $126.00 SCOPE $42.00 APPLIANCE / EQUIP TYPE FEE ID l ' �P�r�>. rd; ��� QTY UNITS BP FEES 1;tt c. 1""' tr,ir FCC, Furnace, Forced -Air IMFR=<100 Orh"'r � lo, Itt c�. Li 1 # $126 11c,"rinit Fee: rS11ppl. I isp I -'c e PME Unit Fee: $126.00 PME Permit Fee: $42.00 C"ons1ruction 7'ax .1c:otdslic al he vie lv Work Without Permit? 0 Yes (E) No $0.00 TOTALS: A Travel Documentation Fee: ITRA VDOC $126.00 Strong Motion Fee: IBSEISMICR �. _.1 •L- n.,nUnh o and aro an)v an intimate. Contact the Dept for addn'1 into. !VV[C: mese ees are based an tae ielsausui v ... J�• FEE ITEMS (Fee Resolution 09-05/E. ',%lilOj Mech. Plan Check0.0 hrs $0.00 l ' �P�r�>. rd; ��� r' r_>�.. Pl an c hc7 Mech. Permit Fee: 1MPERMIT F'Ir r th. N" 'rit t�, 1;tt c. 1""' tr,ir FCC, Mech. Insp. 0.0 hrs '_�SojlA/("(. 1/; 'r I',��, ",Ih It,�,Li I Orh"'r � lo, Itt c�. Li rther it. Inw, 1`ce j°l td Jil:�7. T7 fl. I'Pa' . ft S�;). I` 'F': �. _.1 •L- n.,nUnh o and aro an)v an intimate. Contact the Dept for addn'1 into. !VV[C: mese ees are based an tae ielsausui v ... J�• FEE ITEMS (Fee Resolution 09-05/E. ',%lilOj •..�•• » FEE - -- QTY/FEE - MISC ITEMS I'lun C hack: Fee: slip /. 1"(" 1, ce PME Plan Check: $0.00 11c,"rinit Fee: rS11ppl. I isp I -'c e PME Unit Fee: $126.00 PME Permit Fee: $42.00 C"ons1ruction 7'ax .1c:otdslic al he vie lv Work Without Permit? 0 Yes (E) No $0.00 Planninlg /:CCS A Travel Documentation Fee: ITRA VDOC $42.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $211.50 $0.00 TOTAL'FEE: $211.50 Revised: 12/07/2010 CITY OF CUPERTINO FURNACE/AC CUPEkTINO PERMIT APPLICATION FORM APN # ( Date: Building Address: Owner's Name: Phone #: s 4015-0 s -- a is cA Contractor: c e Ilea,d d � Phone #: c/pj: - 4?3 - 7/7 Fax #: q0k — c9F 3 - (v7-7 Contractor License #: 7!0 $S 7 I Cupertino Business License #: Contact: #: Zlpy -a„2 g .7. y -7/ 7 D'Tor-1a0-1CLrutcy ��Ae- %ic.�Zcr Fax #: �o� a93 ^6-77 Building Permit Info: Elect ❑ Plumb ❑ Mech Residential Commercial Job Description: 2 Cm o v e 6 5Xme LOCA -h0,1- W 1 %`l- A t For Residential Installations: Attic ❑ I" floor Er 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 0 New Location Replacement Project Size: Express ❑ Standard ❑ Large ❑ Major ❑ Valuation: 4 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. xevisea vi/u//u!)