10120083 CITY OF C UPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1157 S STELLING RD CONTRACTOR:CONDITIONED AIR PERMIT NO: 10120083
OWNER'S NAME: BOUDREAU JERAULD F AND PATRICI 1701 LITTLE ORCHARD ST DATE ISSUED: 12/14/2010
OWNER'S PHONE: 4082538517 SAN JOSE,CA 95125 PHONE NO:(408)291-2220
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class J Lic. L-A--6 )UZ REMOVE AND REPLACE FURNACE IN SAME LOCATION
Contractor `7 O " Date IL,
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. Sq.Ft Floor Area: Valuation:$3100
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:36222017.00 Occupancy Type:
i
permit is issued.
APPLICANT CERTIFICATION
I certify that I 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 DA ST CALLED INSPECTION.
indemnify and keep harmless e City of Cupertino against liabilities,judgments, 1�
costs,and expenses which ma accrue against said City in consequence of the Date: 1
granting of this permit. Add ti ally,the applicant understands and will comply Issued by:
with all non- oint source regul`i ions per the Cupertino Municipal Code,Section
9.18.
I RE-ROOFS:
Signature Date t v 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.
❑ OWNER-BUIL ER 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. 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(x)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 def a Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compli ce with th Cupertino Municipal Code,Chapter?.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Section 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent, Date i
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
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify 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/ SU CONTRACTOR LIST
JOB ADDRESS: PERMIT#
OWNER'S NAME® t f J J --1 PHONE
GENERAL CONTRACTOR: lU BUSINESS LICENSE#
ADDRESS: CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL 0 PAtNCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBC TRACTORS HAVE OBTAINED A CITY O CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: i
Signature D to
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
Heating
Insulation
Landscaping
Lathing
Masonry
Painting /Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owne ontractRd Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 1157 s.stelling DATE: 12/14/2010 REVIEWED BY: bobs.
APN: BP#: *VALUATION: 1$3,100
XPERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY SFD or Du lo7I 1r7, PENTAMATION FURN/AC
Duplex USE: p T'1(), 3t:k::Y: 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 Check0.0 hrs $0.00
FMech.Permit Fee: IMPERMITF7 1:,;� Ptrs�ir tE
Other Mech.Insp. Rolhrs $42.00 t), ,, I'r �p 01", ht�
NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addh 7 info.
FEE ITEMS (I,ee Resohitiort 09-051 Elf. 7`1%10) FEE QTYIFEE MISC ITEMS
1'hm C°/uvA P'Ctl
.Sapp/ PC
PME Plan Check: $0.00
e�sn�t Fcc
PME Unit Fee: $126.00
PME Permit Fee: $42.00
Gamstt iwfi n 7'ax
ICOV10i('01licvicu 1"Cc
Work Without Permit? 0 Yes E) No $0.00
Plannia<' FCC)"
Travel Documentation Fee: ITRAVDOC $42.00
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $211.50 $0.00 TOTAL FEE: $211.50
Revised: 12/07/2010
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Building Department
City Of Cupertino
2
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR / UBCONTRACTOR LIST
JOB ADDRESS: <k PERMIT#
OWNER'S NAME: {J v PHONE#
GENERAL CONTRACTOR \u -),f BUSINESS LICENSE#
ADDRESS: CITY/ZIPCODE:
*Our municipal code requires all businesses wor ing�n the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY'jNSPECTION(S) WILL BE SCHEDULED TIL THE
GENERAL CONTRACTOR AN AL SUBCONTRACTORS HAVE OBTAINED A CITY F C PERTINO
BUSINESS LICENSE. ti i/
Ll
I am not using any subcontractors:
nature Date
Please check applicable subcontractors and compl to the following information:
V 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
X.Rheet Roc
Tile
lzl\ A U
Owner/Contra for ture Dat
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 1157 s.stelling DATE: 12/14/2010 REVIEWED BY: bobs.
APN: BP#: *VALUATION: $900
R�PERMITTYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY -107--,,1. PENTAMATION PRWHEATR
USE: SFD or Duplex 1:l 0( R 4"'N',1 PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Heater 1PRWHEATR 1 # $25
TOTALS: I $25.00
f.<:h. Tiarr c'/<ck Plumb.Plan Check 0.0 hrs $0.00
Plumb.Permit Fee: 1PPERMIT
Other Plumb Insp. 0.0 hrs $42.00 Li
NOTE: These -forees are based on the relimina in ormation available and are onl an estimate. Contact the Dept
addn'l info,
FEE ITEMS(Fee Resolution 09-051 El. 7,-7:701 FEE QTY/I'EE MISC ITEMS
P/an Clre(:k 1 cc:
PME Plan Check: $0.00
1'ermii 1`cc.
.`iifppl. 111,'/) T` c>
PME Unit Fee: $25.00
PME Permit Fee: $42.00
C.`onsir oc not, Ta.y
1co!lsti(,al 1cc viesti
Work Without Permit? 0 Yes (F) No $0.00
P1L7it lil ) Fc'c',,.
Travel Documentation Fee: ITRA VDOC $42.00
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $110.50 $0.00 TOTAL FEE $110.50
Revised: 12/07/2010
�
CITY OF CUPERTINO
r
WATER HEATER
CUPEkT1NO PERMIT APPLICATION FORM
10 2 g�
APN# D te:
Building Address:
Owner's ----- Phone #
0
ConPmtor: �, Phone #:
Fax #:
Cupertino Business License #: Contractor State License #:
�-
Contact: Phone #:
Fax #:
Building Permit Info:
r
Bldg �]/� Elect Plumb Mech
i
Residential ❑ Commercial ❑
Job escription: ,
Strapped On Platform F-1Bonded ElNew Location E] R placement
Valuation (cost of project): 00
Project Size: Express D----Standard ❑ Large ❑ Major ❑
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.
Green Building Points achieved: (�7 ---
Revised 03/10/10