13040139 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:-19,916.PRICE AVE CONTRACTOR:A&H HEATING PERMIT NO:13040139
OWNER'S NAME:I EDMOND OR ADA LEUNG 770 CHESTNUT ST DATE ISSUED:04/18/2013
OWNER'S PHONE: 4083730909 SAN JOSE,CA 95110 PHONE NO:(408)279-0722
[3 LIC ENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
11
License Class ' d Lic.# Gu�7 Z REPLACE(E)FURNACE IN ATTIC AND REPLACE(E)A/C
UNIT IN REAR YARD
Contractor Date
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 Section3700 of the Labor Code,for the
performance of the.work for:which this permit is issued. Sq.Ft Floor Area: Valuation:$6050
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:36904028.00 Occupancy T e
permrt!isIssued. P . Y YP
APPLICANT CERTIFICATION
I certify that I have j ead 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 D RMIT 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 DAY T 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 Issu Date:
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.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm'that f 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,''agd the structure isnot intended or offered for sale(See.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 1 Yorker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 2550 and 25534.
Section 3700 of the Labor Code,for.the performance of the work for which this
Owner or authorized agent:
permitis.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 t6't he 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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,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
I'
GENERAL PERMIT APPLICATIONM EP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION' \xo
j 10300 TORRE.AVENUE•CUPERTINO, CA 95014-3255 O
(408)'777-3228 FAX(408)777-3333•building
Ocupertino.org mil.SIC
CUPERTi1+t0
;,E]PUNBING MECHANICAL ❑ELECTRICAL []MISCELLANEOUS
PROJECT ADD}tES ` e/� - n APN#
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OWNER NAMBi,�UI✓`� J Prlil d �� E-MAILL
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CONTACT NAME PHONE
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STREET ADDRESS CITY,STATE,ZIP FAX - -
❑OWNER El 'OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME / LIGE 1�1I]MB�$\r LIcev(C} BUS.LIC#
COMPANY NAL E-MAIL
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ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY INA�v1): E-MAIL FAX -
STREET ADDRESS CITY,STATE,ZIP PHONE
USB OF I.: FD qr DUPLEX. ❑ MULTI-F.AMMY PROJECT IN WBALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDINCr COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME7 ❑NO
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By my signature,below,I certify to',each of the following: I am the property owner or authorized agent to act on t e property owneidP&Ialf I have read this
application and the information I have proodd is correct. I ave cription of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to mg cons
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represen of Cupertino to enter the b ve-identified property for inspection purposes.
Signature ofApplidant/Agent: Date: 7`
i'; ;IIII SUPPLEMENTAL INFORMATION REQUIRED
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III IIII MEPMiscApp_2011.doc revised 06/21/11
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CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 19916 PRICE AVE DATE: 04/18/2013 REVIEWED BY: MELISSA.
APN: 369 04 028 BP#: *VALUATION: 1$6,050
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY PENTAMATION
SFD or Duplex FURN/AC
USE: PERMIT TYPE: �
wORK REPLACE E FURNACE IN ATTIC AND REPLACE E A/C UNIT IN REAR YARD
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
A/C Units (<=10K cfm) 1BREMAIR 1 # $67
Furnace, Forced-Air 1MFR=<100 1 # $133
TOTALS: $200.00
Mech.Plan Check 0.0 hrs $0.00 Phrtnb.Plum Check Elec.Plan Check
Mech.Permit Fee: IMPERMIT Plumb.Permit Pec: Elec. Permit Fee:
Other Mech.Insp. 0.0 hrs $45.00 O dw,Plumb Insp. LL] O cher Mee.Insp,
Mech.1n?p.,Fee: Plumb. Insp.Fee: Elec.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These fees are based on the prelimina information available and are only an estimate Contact the De t or addn'1 info,
FEE ITEMSjFee Resolution 11-053 E . 7111122 FEE QTY/FEE MISC ITEMS
Plcah Check Fee:
Supp 1. PC,Fce .
PME Plan Check: $0.00
Permit Fee:
Sulrx)l. Insp Fee
PME Unit Fee: $200.00
PME Permit Fee: $45.00
Construction :Tax:
Administrative Fee: IADMIN $42.00
Work Without Permit? ®Yes G) No $0.00
Advanced Planning Fes:
Travel Documentation Fee: 1TRAVDOC $45.00
Strong.Motion Fee: 1BSEISMICR $0.61 Select an Administrative Item
Bldg Stds'Commission Fee: IBCBSC $1.00
$333.611 $0.00 s. $333.61
Revised: 04/01/2013