10110076 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10175 CAROL LEE DR CONTRACTOR:VALLEY HEATING& PERMIT NO: 10110076
COOLING
OWNER'S NAME: JANICE CIMINELLO 1171 N 4 TH ST DATE ISSUED: 11/12/2010
JVNER'S PHONE: 4082578527 SAN JOSE,CA 95112 PHONE NO:(408)294-6290
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class C 20 Lic.# %4 4( !T REPLACE FURNACE IN SAME LOCATION
Contractor Lg Y rle ,` (64,4� Date 1�e-'1,2_ -1-4)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:$3192
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:31623075.00 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 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 by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
I r /2/ RE-ROOFS:
Signature ate f l I 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-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
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 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(x)should I store or handle hazardous
1 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 this
Owner or authorized agent: / tii ate
permit is issued. lJ
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
—on the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
:mnify and keep harmless the City of Cupertino against liabilities,judgments,
sts,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
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10175 carol lee dr. DATE: REVIEWED BY:
APN: BP#: *VALUATION: 1$3,192
PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARYSFD or Dulex Tpa. PENTAMATION
USE: '<'' PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Select a Mech Item
Furnace, Forced-Air 1MFR=<100 1 # $126
TOTALS: $126.00 "
Mech.Plan Check 0.0 hrs $0.00
Mech.Permit Fee: IMPERMIT "f.,t t P :
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: j0 i 7-5 Carp Ll e PERMIT#
OWNER'S NAME: -Tcyt Czi,,,i4& PHONE# ge)T-257- 652 7
GENERAL CONTRACTOR: VC,11<X Hec{t,� BUSINESS LICENSE# ii-t t
ADDRESS: 11.71 i4 °f fit St- CITY/ZIPCODE: 5a,, 3a��e F51,'2
*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. ISc
I am not using any subcontractors: J
Signature cr Date
Please check applicable subcontractors and complete 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
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
5 ITEMS OF 11 PERMIT RECEIPT OPERATOR: SylviaM
COPY ## 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 31623075 . 00
DATE ISSUED. . . . . . . : 11/12/2010
RECEIPT #. . . . . . . . . : BS000011985
REFERENCE ID # 10110076
SITE ADDRESS . . . . . : 10175 CAROL LEE DR
SUBDIVISION . . . . . . .
CITY * * . . . * * * * * * ' * : CUPERTINO
IMPACT ARE . . . . . . .
OWNER JANICE CIMINELLO
ADDRESS . . . . . . . . . . : 1523 JAMESTOWN DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2301
RECEIVED FROM . . . . : VALLEY HEATING
CONTRACTOR . . . . . . . : ATKINSON, THOMAS LIC # 141
COMPANY . . . . . . . . . . : VALLEY HEATING & COOLING
ADDRESS . . . . . . . . . . : 1171 N 4 TH ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95112
TELEPHONE . . . . . . . . : (408) 294-6290
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- -------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 3, 192 . 00 1. 00 0 .00 1. 00 0. 00
1BSEISMICR VALUATION 3, 192 . 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
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
CITY OF
CITY OF CUPERTINO
49 FURNACE/AC
CUP RTINO PERMIT APPLICATION FORM
/b//T7
APN# 2 �5 Date:
/� /V/ 2 /16
IV/ 2
Building Address:
5 C..Grpj Zee br:'✓e
Owner's Name: J / Phone#: qos- '5 7-;5�52 :7
Contractor:, / /� d Phone#: 408'-2jq_Ccs.Zq 6
VgIIey Yer, C..(�Olrirtr Fax#: 40 _2.4At- ' ZqF
Contractor License#: \1 Cupertino Business License#:
Contact: _ Phone#: 4t08-2 Q,f_(02 g d°
Fax#:
Building Permit Info:
Elec� Plumb Mech
Residential Commercial ❑
Job Description: r
p r�cfne,'CC' fZ e ta,cCrycCMe �dres'f.ca•Z...
For Residential Installations:
Attic ❑ 1St floor 2nd 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 ❑ Replacement
Project Size: Express [� Standard ❑ Large ❑ Major❑
Valuation: .-5 Iq
-%
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 01/07/09