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11020014 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10140 RICHWOOD DR CONTRACTOR:ALL HOME APPLIANCE PERMIT NO: 11020014 REPAIR OWNER'S NAME: AL ORTIZ 1630 TIERRA BUENA DR DATE ISSUED:02/03/2011 NER'S PHONE: 6509615000 SAN JOSE,CA 95121 PHONE NO:(408)223-9430 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL �I License Class �— �L Li,.# b 3 REMOVE&REPLACE FURNACE Contractorrift X44du6 (1Cr1,-1Lr.; ate Z_ 7 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:$0 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:36908033.00 Occupancy Type: 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 DAYS FRO 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 -2-- 3 r granting of this permit. Additionally,the applicant understands and will comply Issued by: ate: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date �� 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. LJ OWNER-BUILDER 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) 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 25505,25533,and 25534. I 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 I 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 I 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 thisOwner or authorized agent: �'%�-�_ . �--�( Dater 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 CONSTRUCTION LENDING AGENCY 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 �lemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION As,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 CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN 36908033 . 00 DATE ISSUED. . . . . . . : 02/03/2011 RECEIPT #. . . . . . . . . : BS000012637 REFERENCE ID # . . . : 11020014 SITE ADDRESS . . . . . : 10140 RICHWOOD DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . : OWNER AL ORTIZ ADDRESS 10140 RICHWOOD DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : RAMON RUIZ CONTRACTOR . . . . . . . : RAMON CORONA RUIZ LIC # 32347 COMPANY . . . . . . . . . . : ALL HOME APPLIANCE REPAIR ADDRESS . 1630 TIERRA BUENA DR CITY/STATE/ZIP . . . : SAN JOSE, CA 95121 TELEPHONE . . . . . . . . : (408) 223-9430 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 0 . 00 1 . 00 0 . 00 1 . 00 0. 00 1BSEISMICR VALUATION 0 . 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 ----------------- --------------- -------------------- CREDIT CARD 211. 50 visa --------------- 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 ADDRESS: 10140 Richwood Dr DATE: 02/03/2011 REVIEWED BY: RDW APN: BP#: j(O 2 (90(4 *VALUATION: 1$1,600 xPERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION FURN/AC USE: PERMIT TYPE: WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Furnace, Forced-Air 1MFR=<100 1 # $126 TOTALS: 1 $126.00 Mech.Plan Check0.0 hrs $0.00 F Mech.Permit Fee: 1 MPERMIT Other Mech.Insp. 0.0 hrs Lj Li $42.00 r . L NOTE: Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn 7 info. FEE ITEMS (Fee Resolution 09-051 &E T'1./10) FEE QTY/FEE MISC ITEMS flat. C hcc/ Fcc,. PME Plan Check: $0.00 F cc°: 1 c c PME Unit Fee: $126.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes E) No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 A 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: Building Department City Of Cupertino La 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: vVERMIT# / a ZcDO J L4 OWNER'S NAME: re PHONE # GENERAL CONTRACTOR ' � BUSINESS LICENSE# Q 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 OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. 1 am not using any subcontractors: Z .� 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 Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date CITY OF CITY OF CUPERTINO em FURNACE/AC CUPERTINO PERMIT APPLICATION FORM APN# Date: Building Address: If residential, is house an Eichler? Yes ❑ No ❑ If yes, needs planning approval. Owner's Name- Phone #: Contractor: ` , ? Phone#: !'�11 7% u� t�' `�-c� . t Y' Fax #: Contractor License #: .. / Cupertino Business License#: C 2 9c Contact: Phone #: Yv h Fax/e-mail: Building Permit I o: Elect ❑ Plumb ❑ Mech Residential ❑ Commercial ❑ Job Description: 1 - 2 For Residential Installations: Attic ❑ 1St floor 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 Re uired ❑ Cost of Project: Type of Construction(Usage Class): Strapped On Platform ❑ Bonded ❑ New Location ❑ Replacement �- Project Size: Counter ❑ Express ❑ Standard ❑ Large ❑ Major ❑ Valuation: 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. Revised 12/06/10