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10100070I CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 21330 VAI AVE NER'S NAME: CAROL MARMON OWNER'S PHONE: 4082466314 ❑ LICENSED CONTRACTOR'S DECLARATION License Class 13 Lic. # Contractor t} V ��,Cate 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 whichthis permit is issued. 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 is issued. 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 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, 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 9.18. nature Date*4v A ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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 construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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 whichthis permit is issued. 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 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 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. 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 uilding construction, and hereby authorize representatives of this city to enter in the above mentioned property for inspection purposes. (We) agree to save 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 with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date CONTRACTOR: ROBERT LOUTH PERMIT NO: 10100070 C.D. 1'20 CAROL AVE DATE ISSUED: 10/08/2010 BIJRLINGAME, CA 94010 PHONE NO: (650) 4384637 BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r— MECH RESIDENTIAL COMMERCIAL f— JC B DESCRIPTION: FURNACE REPLACEMENT IN THE SAME LOCATION Sq Ft Floor Area: Valuation: $8000 APN Number: 36205030.00 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Iss Lied b Date: RE -ROOFS: 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. Sig Nature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I W ve read the hazardous materials requirements under Chapter 6.95 of the Cal fornia Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Hea Ith & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air ,:ontaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25 05, 25533, and 25534. 1 OwAcr or authorized agent: IL Date: it1 CONSTRUCTION LENDING AGENCY I hei eby affirm that there is a construction lending agency for the performance of worl 's for which this permit is issued (Sec. 3097, Civ C.) Len Ier's Name Len Ier's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Lice hsed Professional CITY OF CUPERTINO F -M-7- FEE ESTIMATOR — BUILDING DIVISION APPLIANCE / EQUIP TYPE ADDRESS: DATE: REVIEWED BY: UNITS APN: BP#: *VALUATION: 1$8,000 PERMIT TYPE: Mechanical Permit PLAN C14ECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex lex USE: � {; �� - �t' -' `==�_: PENTAMATION FURN/AC PERMIT TYPE: WORK Fcc: SCOPE ,S'irlyV, 111 sp FC" APPLIANCE / EQUIP TYPE FEE ID '= << QTY UNITS BP FEES Furnace, Forced -Air J 1MFR=<100 1 # $126 Fcc: ,S'irlyV, 111 sp FC" PME Unit Fee: $126.00 PME Permit Fee: $42.00 F -1o Work Without Permit? 0 Yes 0 No $0.00 TOTALS: Travel Documentation Fee: ITRAVDOC 1 $126.00 Strong Motion Fee: NOTE: These fees are based on the nreliminary information availa ble and are only an estimate. Contact the Dent far addn'1 info FEE ITEMS (Fee Resolution 09-05I Elf. 7'1./10) Mech. Plan Check 0.0 hrs $0.00 '= << : ,_�� _ z.i [Mech. Permit Fee: IMPERMIT Other Mech. Insp. 0.0 hrs $42.00 ( PME Plan Check: $0.00 NOTE: These fees are based on the nreliminary information availa ble and are only an estimate. Contact the Dent far addn'1 info FEE ITEMS (Fee Resolution 09-05I Elf. 7'1./10) FEE QTY/FEE MISC ITEMS Phlil Clwc t" /`E c: .S11"'? / P(' PME Plan Check: $0.00 Fcc: ,S'irlyV, 111 sp FC" PME Unit Fee: $126.00 PME Permit Fee: $42.00 F -1o Work Without Permit? 0 Yes 0 No $0.00 Travel Documentation Fee: ITRAVDOC $42.00 Strong Motion Fee: $0.80 Select an Administrative Item _7 Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $211.80 $0.00 TOTAL FEE: $211.80 Revised: 9/29/2010 CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: bethe COPY # : 1 Sec: Twp: Rng: Sub: Blk: I,ot: APN ........: 36205030.00 DATE ISSUED.......: 10/08/2010 RECEIPT #.........: BS000011686 REFERENCE ID # ...: 10100070 SITE ADDRESS .....: 21330 VAI AVE SUBDIVISION ....... CITY CUPERTINO IMPACT AREA ....... OWNER CAROL MARIDON ADDRESS ..........: 21330 VAI AVE CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: ROBERT LOUTH CONTRACTOR .......: ROBERT LOUTH CO. LIC # 30030 COMPANY ..........: ROBERT LOUTH CO. ADDRESS ..........: 1520 CAROL AVE CITY/STATE/ZIP ...: BURLIYGAME, CA 94010 TELEPHONE ........: (650) 438-4637 FEE ID UNIT QUANTITY AMOLNT PD -TO -DT THIS REC NEW BAL ---------- 1BCBSC ------------- VALUATION ---------- 8,000.00 ---------- 1.00 ---------- 0.00 ---------- 1.00 ---------- 0.00 1BSEISMICR VALUATION 8,000.00 0.80 0.00 0.80 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 ---------- 211.80 ---------- 0.00 ---------- 211.80 ---------- 0.00 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT : AMOUNT --------------- 211.80 --------------- 211.80 VOICE ID DESCRIPTION -------- ---------------------------- 505 FINAL ELECTRICAL 508 FINAL MECHANICAL REFERENCE NUMBER -------------------- 1410 VOICE ID DESCRIPTION -------- ---------------------------- 507 FINAL PLUMBING CUPERTINO CONTRACTOR / SUB CONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS:3 0. PERMIT # Q OCA OWNER'S NAME: % u to PHONE # GENERAL CONTRACTOR:y A) BUSINESS LICENSE # ADDRESS: S,ZQCava V CITY/ZIPCODE: <."I "lull t, pal cuue requires au ousinesses worKing in th(, 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: Signai ure Date Please check applicable subcontractors and complete the following information: 311CCL 1f OC%K Tile TZ Owner / Contractor Signature Date 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 311CCL 1f OC%K Tile TZ Owner / Contractor Signature Date aC10F CUPEkTINO CITY OF C UPERTINO FURNACE/AC PER HT APPLICATION FORM 101000-70 APN # Date: Building Address: Owner's Name: Cq V0 VM Lt V t 0 L'I Phone #: 6 56/-Z46 6 3 1 Contractor: Phone #: Rkvl -t Y I- Fax #: Contractor License #: Cupertino Business License #: Contact: Phone #: �,�U ki ]IV ' LVt Fax #: Building Permit Info: Elect ❑ Plumb ❑ Mech Residential Commercial Job Description: VLA -r 5 -C. d c uta lUt� For Residential Installa ons: Attic El I' floor [y 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 ❑ Type of Co(Usage Class): Cost of Project: Type 'truction `ns If 8/ V �v�l� V V 666 p Strapped On Platform LJ BondedEl New Location Replacement Project Size: Ex ressStandard ❑ Large ❑ Major ❑ Valuation: Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the —I._ !.0 _ 12 1-11 ,.l.. d.. ..1.. ..+ .Q. +1.o c.1.nn+i�.�ov ✓ aPP1lcaLloll Vl u appucaule, i.ncluue ill plan JcL WA, &iia, ou%.%.%. aaa..v.s. Q Revised 01/07/09