10010028CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22286 S DE ANZA CIR
OWNER'S NAME: HUMPHREY ROBERT A AND VIOLET L
K
Li
C1
ER'S PHONE: 4089962207
LICENSED CONTRACTOR'S DECLARATION
C
;ense Class ' 2
Lic. # 1 moi- 747--
>ntractor Date "� I L
Hereby affirm that I am licensed under
ommencing with Section 7000) of Division 3 of the Business &Professions
ode and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the following two declarations:
have and will maintain a certificate of consent to sae Labor Codinsure for e, for Worker's
the
ompensation, as provided for by Section 3700 of t
erformance of the work for which this permit is issued. provided for by
have and will maintain Worker's Compensation Insurance, as p
ection 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
CONTRACTOR: A & H HEATING
770 CHESTNUT ST
PERMIT NO: 10010028
DATE ISSUED: 01/07/2010
SAN JOSE, CA 95110 PHONE NO: (408)279-0722
BUILDING PERMIT INFO: BLDGELECT PLUMB,
M
ECH F RESIDENTIAL r— COMMERCIAL
JOB DESCRIPTION: REMOVE & REPLACE OLDD FURNACE IN SAME
LOCATION
Sq. Ft Floor Area:
APN Number: 35602017.00
APPLICANT CERTIFICATION
certify that I have read this application and state that the above information is
,orrect. I agree to comply with all city and county ordinances resentatives ofthistc city t centering
Lo building construction, and hereby authorize rep agree to save
upon the above mentioned property for inspection purposes. (We)
indemnify and keep harmless the City of Cupertino nt sa d City magainst
consequence of the
against
ts,
costs, and expenses which may accrueag
granting of this permit. Additionally, the applicant understands and will comply
with all non -point sourc gulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
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)
I, 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 t
Compensation, as provided for by Section 3700 of the Labor Code
he
performance of the work for which this permit is issued. provided for by
I have and will maintain Worker's Compensation Insurance, as p
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
become subject to the Worker's
not employ any person in any manner so as to
Compensation laws of California. If, after making this certificate the Labor Code, mus
become subject to the Worker's Compensation provisions o
forthwith comply with such provisions or this permit shall be deemed revoked.
Valuation: $2500
Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Date: /•—r��
Issued bye__
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.
Date:
Signature of Applicant:
APPLICANT CERTIFICATION ation is
I certify that I have read this application and state that
the aes ve and state laws relating
info
correct. I agree to comply with all city and county o
to building construction, and hereby authorize representatives of this city to
upon the above mentioned property for inspection purposes. (We) agree to judgments,
it iify and keep harmless the City of pagainst
sequence of the
c .nd expenses which may accrue against sa d C City in consequence
understands and will comply
gray ting of this permit. Additio ly, the app
with all non -poi source ations per the Cupertino Municipal Code, Section
9.18.
Signature
Datel::'1 _._'1 _ /C3
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements
25533, andChapter
25534. I w ll
9the
maintain
California Health & Safety Code, Sections
compliance with the Cupertino Municipal Code,
Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I storehandle
emit hazardous airl.
Additionally, should I use equipment or devices which
contaminants as defined by the Bay Area Air Quadty Municipalodeq Chapter Dista dI will
he
maintain compliance with the Cupertino ode Sections 25505, 25533a 25534.
Health �r.,Safe
O ent:1
Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address,
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
7 ITEMS OF 7
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 35602017.00
DATE ISSUED.......: 01/07/2010
RECEIPT #.........: BS000009506
REFERENCE ID # ...: 10010028
SITE ADDRESS .....: 22286 S DE ANZA CIR
SUBDIVISION .......
CITY .............. CUPERTINO
IMPACT AREA .......
OPERATOR: patg
COPY # : 1
OWNER ............: HUMPHREY ROBERT A AND VIOLET L
ADDRESS ..........: 22286 S DE ANZA CIR
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT :
AMOUNT
232.50
232.50
VOICE ID DESCRIPTION
505 FINAL ELECTRICAL
508 FINAL MECHANICAL
REFERENCE NUMBER
VISA
VOICE ID DESCRIPTION
507 FINAL PLUMBING
RECEIVED FROM ....: REINHARDDALELHELICR#
CONTRACTOR
........ PHELPS,
12079
COMPANY ..........:
A & H HEATING
ADDRESS ..........:
770 CHESTNUT
ST
CITY/STATE/ZIP
...: SAN JOSE, CA
95110
TELEPHONE
........: (408)279-0722
QUANTITY AMOUNT
PD -TO -DT-
THIS
FEE ID
UNIT
------
-REC- --NEW
-
-BAL-
-----
1BCBSC
-------------
VALUATION
---------------- - ---
2500.00 1.00
,
0.00
1.00
0.50
0.00
0.00
1BSEISMICR
VALUATION
21500.00 0.50
42.00
0.00
42.00
0.00
1EPERMITFE
FLAT RATE
1.00
.
1.00 4200
0.00
42.00
0.00
1MPERMITFE
FLAT RATE
1.00 63.00
0.00
63.00
0.00
1MRRAA
UNITS
1.00 42.00
0.00
42.00
0.00
1PPERMITFE
FLAT RATE
1.00 42.00
0.00
42.00
0.00
1TRAVDOC
FLAT RATE
232.50
0.00
232.50
0.00
TOTAL PERMIT
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT :
AMOUNT
232.50
232.50
VOICE ID DESCRIPTION
505 FINAL ELECTRICAL
508 FINAL MECHANICAL
REFERENCE NUMBER
VISA
VOICE ID DESCRIPTION
507 FINAL PLUMBING
CITY OF CUPERTINO
FURNACE/AC
CUPEI�TINO PERMIT APPLICATION FORM
Dat
l:' 1
-7 , c�'
Buildin Addres
Pone#:
Owner's Name: 47 _J 6 '-Z 20*7
Phone #: 'Z c,
Contractor:
Fax #: `7�� poi -7
Cupertino Business License #:
Contractor License #:
2
Phone #: i S CY% 2
Contact:
l Fax M
�e-
Per Building mit Info:
Elect Q .
- . � Plumb Mech
��
Residential
Commercial ❑
;�
Job Description:
For Residential Installations:t 2nd floor El
is
Attic
floor--
Adhere to minimum setback requirement ❑
For Commercial Installations:
Additional weight (structural calcs) ElReplacement same weight F]
Structural Calculations required for new installation El
New installation Planning Approval Required ❑
of Project: Type of Construction (Usage Class):
Cost � �
4
1-4 V
---------- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Strapped ❑ On Platform ❑
Bonded ❑ New Location ❑ Replacements
Size: Ex ❑ Standard �— Large ❑ Major ❑
Project S Express[]
Valuation: 17 �l
' the
' •Please com Tete relevant portion of the Green Building Checklist &attach it to
Green Building. P
application or if applicable, include in plan set & the sheet index.
Revised 6/16/08
CUPF TiNO
FURNACE
1PGASRES
1BPGAS
r 1BSEISMICR
1
CITY OF CUPERTINO
FURNACE/AC
FEE SCHEDULE
Group
FURN/AC
Residential for ea gas piping system of P
1-4 Outlets
For each gas piping system of 5 or P
more per outlet.
Residential Seismic B
1MECPLNCK Mechanical Plan Check I M
1 TRAVDOC Travel Documentation B
1 BUSLIC Business License B
n..antity Fee ID Fee DFee I Permit
1MFR=<100
Furnace Syst <=100k BTU install or
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance up to and
include 100,000 Btu/h
Furnace Syst > 100k BTU install or
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance over
100,000 Btu/h
Electric Permit Fee
Mechanical Permit Fee
Plumbing Permit
M
M
1 MFRN> 100
1EPERMITFEE
1MP ERMITFEE
E
M
P
1 PPERMITFEE
1 TRAVDOC Travel Documentation B
1 BUSLIC Business License B
n..antity Fee ID Fee DFee I Permit
Community Development
10300 Torre Avenue
}; Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
CIT1f OF
,U PEkTINo
Buildion
De artment
ADDRESS: PERMIT
42 -2 '2 0 �-. . h'%00� Cf-,V"I-L S ----------
JOB
'S NAME: '�! >'t"4 PHONE 2? C
OWNER
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: Date
Please check a
Signature
nnA i-r)mnlete the foll
/ Contractor Signature
;rcr infnrmA' ion:
Date
M. Indoor Air uuauty al lu v 11 loo,
1 IAQ/Health pts
y=yes
1. Use Low/No-VOC Pai'M
4 Resource pts
y=yes
2. Use Low VOC, Water -Based Wood Finishes
2 IAQ/Health pts
y=yes
3. Use Low/No VOC Adhesives
3 IAQ/Health pts
y=yes
4. Use Salvaged Materials for Interior Finishes
3 Resource pts
y=yes
5. Use Engineered Sheet Goods with no added Urea
4 Resource pts
y=yes
Formaldehyde
6 IA(yHealth p is
y -y es
6. Use Exterior Grade Plywood for Interior Uses
1 IAQ/Health pts
y=yes
7 Seal all Exposed Par#iclboard or MDF
4 IAQ/Health pts
y=yes
B. Use FSC Certified Materials for Interior Finish
4 Resource pts
y=yes
9. Use Finger -Jointed or Recycled -Content Trim
1 Resource pts
y=yes
10. Install Whole. House Vacuum System
3 IAQ/Health pts
y=yes
N. Flooring
1. Select FSC Certified Wood Flooring
8 Resource pts
y=yes
2. Use Rapidly Renewable Flooring Materials
4 Resource pts
y=yes
3. Use Recycled Content Ceramic Tiles
4 Resource pts
y=yes
4. Install Natural Linoleum in Place of Vinyl
5 IAQ/Health pts
y=yes
5. Use Exposed Concrete as Finished Floor
4 Resource pts
y=yes
6. Install Recycled Content Carpet with Low VOCs
4 Resource pts
y=yes
ro--tal Points Availab e:
Total Points Project Received:
PC
X
0
0
L
1401 130 57
;0 0 0
L
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