10010160 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11556 FALLCREEK SPRIN CT CONTRACTOR:A PLUS HEATING&A/C PERMIT NO: 10010160
OWNER'S NAME: ROBERTS,GARY 244 GREAT MALL PKWY DATE ISSUED:01/27/2010
;ER'S PHONE: 4082532628 MILPITAS,CA 92683 PHONE NO:(408)934-0730
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT F PLUMB F
License Class C -2� Lic.#
MECH� RESIDENTIAL� COMMERCIAL
oll
2_6(o
Contractor c.__Date 1 `
I hereby affirm t t I am licensed under the provisions of Chapter 9
JOB DESCRIPTION:CHANGE FURNACE,SAME LOCATION
(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:$3500
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 this
APN Number:36651023.00 Occupancy Type:
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 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 b Date:,
P Y
9.18.
Signaturez Date l �/0
RE-ROOFS:
L, 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)
1,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
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
1 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 Owner&Wap
JheriZCd_Wnt: (-7
Compensation laws of California. If,after making this certificate of exemption,IDate:
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. CONSTRUCTION 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
upon the above mentioned property for inspection purposes.(We)agree to save
-inify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
and expenses which may accrue against said City in consequence of the
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
Si#ature �'` Date l`� r
CITY OF CUPERTINO
PERMIT RECEIPT OPERATOR: patg
7 ITEMS OF 7 COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 36651023 . 00
DATE ISSUED. . . . . . . : 01/27/2010
RECEIPT #. . . . . . . . . : BS000009633
REFERENCE ID # 10010160
SITE ADDRESS . . . . . : 11556 FALLCREEK SPRIN CT
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER ROBERTS, GARY
ADDRESS 11556 FALLCREEK SPRING CT
CITY/STATE/ZIP CUPERTINO CA, CA 95014-5118
RECEIVED FROM . . . . : APLUS HEATING & AIR
CONTRACTOR . . . . . . . : ADAM P. PHAM LIC # 31293
COMPANY . . . . . . . . . . : A PLUS HEATING & A/C
ADDRESS . . . . . . . . . . : 244 GREAT MALL PKWY
CITY/STATE/ZIP . . . : MILPITAS, CA92683
TELEPHONE (4 0 8) 934-0730
- --FEE ID
UNIT QUANTITY AMOUNT PD-TO-DT- _THIS-REC- _-NEW_BAL-
--- ---- ----------
---- ---------- 1. 00 0 .00 1.00 0 . 00
1BCBSC VALUATION 3, 500 . 00 . 50 0 .00 0 .50 0 . 00
1BSEISMICR VALUATION 3, 500 .00 0 0 . 00
1 . 00 42 . 00 0 .00 42 .00
lEPERMITFE FLAT RATE 1 .00 42 . 00 0 . 00 42 . 00 0 . 00
1MPERMITFE FLAT RATE 1. 00 63 . 00 0 . 00 63 .00 0 .00
1MRRAA UNITS 0 . 00 42 . 00 0.00
1PPERMITFE FLAT RATE 1 . 00 42 . 00 0.00
1 . 00 42 . 00 0 . 00 42 . 00
1TRAVDOC FLAT RATE ---------- ----------
TOTAL PERMIT
----
--_-_-� -�� 232 . 50 0. 00
REFERENCE NUMBER
AMOUNT
METHOD OF PAYMENT _________
CHECK 232 . 50 #1174
---------------
TOTAL RECEIPT 232 . 50
CE ID DESCRIPTION
VOICE ID DESCRIPTION VOI --
-------- ------------------ 507 FINAL PLUMBING
505 FINAL ELECTRICAL
508 FINAL MECHANICAL
CITY OF CUPERTINO
R FURNACE/AC
LUPE OF
PERMIT APPLICATION FORM
APN # ..., Date: /,-2"?
� J
Building Address:
C1 IT 56 f-AIIc 5 �� _�� ct
Owner's Name: 1 .) Phone#:
c C-7 ci, K y 'fo e -
Contractor: Phone#:Lfo S - 931 _D� 30
1 V r c V� Lc Fax#: L, CC if 0-f 3'f
Contractor License#: Cupertino Business License#:
-76 3
Contact: Phone#: Lto b - q 3 9 - OT-30
Fax #: `t O b T3tf 0.7 3
Z4 L LK �-o
Building Permit Info:
Elect D-�' Plumb Mech ❑`---
Residential 0 Commercial ❑
Job Description:
For Residential Installations:
Attic F] 1St floor �, 2nd floor ❑
Adhere to minimum setback requirement El
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 Constructi n (Usage Class):
Strapped I--] On Platform F-1 BondedNew 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
CITY OF CUPERTINO
i, FURNACE/AC
CITY°FFEE SCHEDULE
CU PEkTINO
Quantity Fee ID Fee Description Fee 7Permit Type
Group
1 MRAPPVNT Residential for the install/relocate/or M
replacement of ea appliance vent
install ¬ incl in an appl permit.
FURNACE FURN/AC
1 PGASRES Residential for ea gas piping system of P
1-4 Outlets
1 BP GAS For each gas piping system of 5 or P
more per outlet.
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1 BSEISMICR Residential Seismic B
1 MECPLNCK Mechanical Plan Check M
M
1 MFR=<100 Furnace Syst<=100k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance up to and
include 100,000 Btu/h
1 MFRN>100 Furnace S yst> l 00k BTU install or M
relocate ea forced-air/gravity type
furnace/bumer, incl ducts/vents
attached to such appliance over
100,000 Btu/h
1 EPERMITFEE Electric Permit Fee E
-j- 1 MPERMITFEE Mechanical Permit Fee M
1PP
ERMITFEE Plumbing Permit P
1 TRAVDOC Travel Documentation B
1 BUSLIC Business License B
Energy t
INPUT Re5ources
M.Indoor Air Qua sty an Finishes
1 IAQ/Health pts y=yes 0
1.Use�.wrrll�VOC Pam 0
2.Use Low VOID,Water-Based Wood Finishes 2 IAQ/Health pts y=yes.
3.Use LowlWcif SOC Ate
31AQ/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea 0
Formaldehyde 61AQ/Health pts y=yes
Y 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts Y= es 0
41AQ/Health pts y=yes
7.deaf�: Pde�x�ar�=DrF 0
8.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 0
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 0
1 � 1
0
N.Flooring
1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0
2.Use Ra dy Renewable Flooring Ma#erials 4 Resource pts y=ye5 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=ye5 0
0
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 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yeS 0
1 1 1
1
Total Points Available: 140 130 57
Total Points Pro'ect Received: 0 0
G:datalprogs/greenbuildingguidelines/remodelerslgreenpointsfinal2.12.04protected.xls
Community Development
10300 Torre Avenue
a�
Cupertino CA 95014
ZY rF�
Telephone(408)777-3228
CITY OF Fax(408)777-3333
"U PEkTINO
Building Department
JOB ADDRESS: PERMIT #
OWNER'S NAME: ,b,�V-zh C` IQ PHONE # Lf o - S3 �-�-C.,z5
GENERAL CONTRACTOR: V s FAX #
I am not using any subcontractors:
Signa e Date
Please check ap icable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date