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10110146
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20671 MC CLELLAN RD CONTRACTOR:PELLE HEATING&AC INC PERMIT NO: 10110146 0" 'vR'S NAME: GARY FONG 3728 C CHARTER PARK DR DATE ISSUED: 11/22/2010 OWNER'S PHONE: 4082303921 SAN JOSE,CA 95136 PHONE NO:(408)978-7060 ❑ LICENSED CONTRACTOR'S DEECpL-ARATION BUILDING PERMIT INFO: BLDG r— ELECT r— PLUMB r License Class e," Lic.# f� , � , MECH r— RESIDENTIAL r— COMMERCIAL/� Contractor T le //�W ��Date I hereby affirm that I am lic d under the provisions of Chapter 9 JOB DESCRIPTION: 80,000 BTU FURNACE CHANGEOUT (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:$5526 1 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 thy_, permit is issued. �� APN Number:35916008.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,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 Issued 9.18. ure Date RE-ROOFS: ❑ OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&Safety Code,Sections 25505,25533,and 25534. 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 r or author' nt• 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. C NSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address `he above mentioned property for inspection purposes.(We)agree to save nify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date ACORD CERTIFICATE OF LIABILITY INSURANCE DAT TM. 0903/2010 PRODUCER Phone: 408-297-6686 Fax: 408-280-2110 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION SENIGAGLIA INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 950 S.BASCOM AVE.,SUITE 2113 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR SAN JOSE CA 95128 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. I INSURERS AFFORDING COVERAGE NAIC# Agency Lic#:0669522 INSURED INSURER A: Truck Insurance Exchange PELLE HEATING 8r AIR,INC. INSURER B: 3728-C CHARTER PARK DRIVE INSURER C: SAN JOSE,CA 95136 INSURER D_ INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR NDSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE MM/DD I DATE MM/DD/YY GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY( DAMAGE TO RENTED $ PREMISES(Ea occurence) CLAIMS MADE OCCUR MED.EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG. $ PRO- POLICY JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT — ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY (Per person) $ SCHEDULED AUTOS HIRED AUTOS _. BODILY INJURY $ NON-OWNED AUTOS (Per accident) I PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ I'I ANY AUTO j OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ ---J $ --- DEDUCTIBLE $ RETENTION$ $ C STATIJ_ WORKERS COMPENSATION AND A0928 71 96 09/01/10 09/01/11 X J TORY LIMITS OTHER EMPLOYERS'LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 1,000 000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1,000 000 OTHER: DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY(ENDORSEMENT/SPECIAL PROVISIONS Certificate of Insurance CERTIFICATE HOLDER CANCELLATION MASTER CERTIFICATE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Attention: eff Senigaglia ACORD 25(2001/08) Certificate# 20662 ©ACORD CORPORATION 1988 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Its Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: 7//�C 'rle moi! PERMIT# 07 L-t OWNER'S NAME: PHONE # GENERAL CONTRACT-04<: C 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 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 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 10 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35916008 . 00 DATE ISSUED. . . . . . . : 11/22/2010 RECEIPT #. . . . . . . . . : BS000012069 REFERENCE ID # . . . : 10110146 SITE ADDRESS . . . . . : 20671 MC CLELLAN RD SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . . GARY FONG ADDRESS . . . . . . . . . . : 20671 MC CLELLAN RD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : PELLE HEATING & AIR CONTRACTOR . . . . . . . : STEVE PELLE LIC # 27593 COMPANY . . . . . . . . . . : PELLE HEATING & AC INC ADDRESS . . . . . . . . . . : 3728 C CHARTER PARK DR CITY/STATE/ZIP . . . : SAN JOSE, CA 95136 TELEPHONE . . . . . . . . : (408) 978-7060 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 5, 526. 00 1 .00 0 .00 1. 00 0 . 00 1BSEISMICR VALUATION 5, 526. 00 0 .55 0 .00 0 .55 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 211.55 0. 00 211. 55 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 423 .05 #4652 --------------- TOTAL RECEIPT 423 .05 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 20671 mcclellan rd DATE: 11/22/2010 REVIEWED BY: bobs. APN: BP#: *VALUATION: 1$5,526 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex lex 7UI.,L PENTAMATION FURN/AC USE: 1 r>�tiz - 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 Check Rolhrs $0.00 Pfol7ll' 1 /(W %: Mech.Permit Fee: 1MPERMIT3f ,r Other Mech.Insp. 0.0 hrs $42.00Li NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'l info. FEE ITEMS (Fee Resolution 09-051 Elf. 7%1%70) FEE QTY/FEE MISC ITEMS P/011 C/lc"i FC"- �11pp/' PC F—l'"(. PME Plan Check: $0.00 PME Unit Fee: $126.00 PME Permit Fee: $42.00 ("0i1S0'1W1i0P1 T'1Xh "I':ouslical1?cv '11 Vt"' : Work Without Permit? 0 Yes (E) No $0.00 /'lrlrrlTlu,�r f�'��c s: Travel Documentation Fee: ITRAVDOC $42.00 Strong Motion Fee: IBSEISMICR $0.55 Select an Administrative Item Bldg;Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $211.55 $0.00 TOTAL FEE: $211.55 Revised: 11/08/2010 , 01 QA CITY OF CITY OF CUPERTINO FURNACE/AC CUPERTINO PERMIT APPLICATION FORM APN # t� Date: C' 9-0[ O Building Address: g,( L.rl 1 RcCIt:--t lcLvi Owis Name: Phone#: ay�A a 30.3Gi �1 Contractor: Phone#: �et IPi � Ca t)\ Fax#: %'-Wrg Contractor License#: Cupertino Business License#: Contact: Phone#: `t ,'t' . l cin V1�2. vV n V-1 6tey-)OE-_f Fax#: Building Permit Info: Plumb [� Mech Elect • Residential Commercial ❑ Job Description: For Residential Installations: Attic ❑ 1 st 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 Required ❑ Cost of Project: Type of Construction (Usage Class): Strapped ❑ On Platformijul Bonded ❑ New Location ❑ Replacement Project Size: Express ❑ Standard ❑ Lar e ❑ Major❑ Valuation: 8 6 Xcl ` 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