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10110113 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10470 WESTACRES DR CONTRACTOR:ATLAS-TRILLO HVAC PERMIT NO: 10110113 OWNER'S NAME: RANWEILER SHIRLEY R AND THOMAS 1965 KYLE PARK CT DATE ISSUED: 11/17/2010 OWNER'S PHONE: 4082573422 SAN JOSE,CA 95125 PHONE NO:(408)286-8931 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ REMOVE&REPLACE EXISTING FURNACE License Class, I r Contractorate I hereby affirm thovisions of Chapter 9 (commencing withf the Business&Professions Code and that my license is in full force and effect. Sq.Ft Floor Area: Valuation:$3000 1 hereby affirm under penalty of perjury one of the following two declarations: t. 1 have and will maintain a certificate of consent to self-insure for Worker's APN Number:35916014.00 Occupancy Type: Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 2. 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 EXPIRES IF WORK IS NOT STARTED permit is issued. WITHIN 180 DAYS OF PERMIT ISSUANCE OR APPLICANT CERTIFICATION 180 DAYS FROM LAST CALLED INSPECTION. 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 Issued by- Date: / ze upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the Ci upertino against liabilities,judgments, costs,and ex crises which may a rue a said City in consequence of the granting of is pe .. dditio lly, e a 'cant understands and will comply with RE-ROOFS: all non-poin source a up unicipal Code,Section 9.18. All roofs shall be inspected prior to any roofing material being installed.If a roof is r� installed without first obtaining an inspection,I agree to remove all new materials for Signature Date ( inspection. Signature of Applicant: Date: OWNER-BUILDER DECLARATION ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: t. 1,as owner of the property,or my employees with wages as their sole HAZARDOUS MATERIALS DISCLOSURE compensation,will do the work,and the structure is not intended or offered for I have read the hazardous materials requirements under Chapter 6.95 of the sale(Sec.7044,Business&Professions Code) California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain 2. 1,as owner of the property,am exclusively contracting with licensed contractors to compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& construct the project(Sec.7044,Business&Professions Code). Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air I hereby affirm under penalty of perjury one of the following three declarations: contaminants as defi the Bay Area Air Quality Management District I will t. I have and will maintain a Certificate of Consent to self-insure for Worker's in Aorh comp a wit Cupertino Municipal Code,Chapter 9.12 and the Compensation,as provided for by Section 3700 of the Labor Code,for the He ty ode, o s 25505,25533,and 25534. performance of the work for which this permit is issued. O nr' ed a en ( (� O 2. I have and will maintain Worker's Compensation Insurance,as provided for by Date: l l Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 3. I certify that in the performance of the work for which this permit is issued,I shall CONSTRUCTION LENDING AGENCY not employ any person in any manner so as to become subject to the Worker's I hereby affirm that there is a construction lending agency for the performance of work's Compensation laws of California. If,after making this certificate of exemption,I for which this permit is issued(Sec.3097,Civ C.) become subject to the Worker's Compensation provisions of the Labor Code,I Lender's Name must forthwith comply with such provisions or this permit shall be deemed Lender's Address revoked. ARCHITECT'S DECLARATION APPLICANT CERTIFICATION I understand my plans shall be used as public records. 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 Licensed Professional 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, cncts,and expenses which may accrue against said City in consequence of the ing of this permit.Additionally,the applicant understands and will comply with ..on-point source regulations per the Cupertino Municipal Code,Section 9.18. Signature Date CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10470 west acres dr. DATE: 11/17/2010 REVIEWED BY: building APN: BP#: 10110113 *VALUATION: 1$3,000 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex Cit°. °` PENTAMATION FURN/AC USE: "-��>��'"fit="-- - PERMIT TYPE: WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Furnace, Forced-Air 1MFR=<100 1 # $126 TOTALS: 1 $126.001 1 Mech.Plan Check 0.0 hrs $0.00 Mech.Permit Fee: IMPERMIT Other Mech.Insp. 0.0 hrs L $42.00 Li -L- E ,i, rt- Li NOTE. Thesefees are based on the preliminary information available and are onl an estimate. Contact the De t or addn'l info, FEE ITEMS (Fee Resohition 09-051 E,l. T'1,10) FEE QTY/FEE MISC ITEMS Plan ChccA FCC: Sapp/. PC`FCC PME Plan Check: $0.00 Pt rinit Fc,c PME Unit Fee: $126.00 PME Permit Fee: $42.00 ConzIrllcfion I'ax "Icol'dslir:('ll FCC, Work Without Permit? 0 Yes E) No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bids;Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $211.50 $0.00 TOTAL FEE: $211.50 Revised: 11/08/2010 CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: suew COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35916014 . 00 DATE ISSUED. . . . . . . : 11/17/2010 RECEIPT #. . . . . . . . . : BS000012034 REFERENCE ID # . . . : 10110113 SITE ADDRESS . . . . . : 10470 WESTACRES DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : RANWEILER SHIRLEY R AND THOMAS ADDRESS . . . . . . . . . . : 10470 WESTACRES DR CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-2963 RECEIVED FROM . . . . : ATLAS TRILLO CONTRACTOR . . . . . . . : TRILLO, STEVE LIC # 4269 COMPANY . . . . . . . . . . : ATLAS-TRILLO HVAC ADDRESS . . . . . . . . . . : 1965 KYLE PARK CT CITY/STATE/ZIP . . . : SAN JOSE, CA 95125 TELEPHONE . . . . . . . . : (408) 286-8931 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 3, 000 .00 1. 00 0 .00 1. 00 0 . 00 1BSEISMICR VALUATION 3, 000 .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 ----------------- --------------- -------------------- CHECK 211. 50 2379 --------------- TOTAL RECEIPT 211. 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CITY OF CUPERTINO FURNACE/AC C U P E RT I N O PERMIT APPLICATION FORM APN # 35Y Date: I I r 7 Building A ress: a QST Gil CS . O d Rm A7 1 V �' v e-/ � _ Phone qC °3 Contractor: f �"� -!S � ) �AT /� hone 12,-336 S I , LeCT S ax #: �7 / Contractor Ll'cenle#: ` Cupertino 143 nn/ess icense#: Contact: -� L't-C) Phone #: Fax#: cS, ) 73V f�>/ Building Perm] .Info: Elect ❑ t Plumb [� Mech Residential%W Commercial ❑ Job Description: 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 Construppctio''nJUsage Class): C7-0--D • - V 4J Strapped ❑ On Platform ❑ Bondedo New Location ❑ Replacement Project Size: 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 01/07/09