09120052 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21900 EATON PL CONTRACTOR:VALLEY HEATING& PERMIT NO:09120052
COOLING
("''NER'S NAME: NANCY FITZWATER 1171 N 4 TH ST DATE ISSUED: 12/09/2009
t,– JER'S PHONE: 4088650921 SAN JOSE,CA 95112 PHONE NO:(408)294-6290
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG f- ELECT PLUMB
License Class -Z0 Lic.# MECH f— RESIDENTIAL f— COMMERCIAL
Contractor �!`� Date L C
I hereby affirm that I am licensed unde the provisions of Chapter 9 JOB DESCRIPTION:REPLACE FURNACE&ADD A/C
(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:$5795
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. APN Number:32619138.00 Occupancy Type:
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 by: .. 'r^ Date:
9.18.
Si—ature Date 4
RE-ROOFS:
❑ 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)
I,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
1 have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 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 o th nt-.
Compensation laws of California. If,after making this certificate of exemption,I Date:
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
the above mentioned property for inspection purposes.(We)agree to save
nify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,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
Signature Date
CITY OF CUPERTINO
FURNACE/AC
CITY OF
CUPERTINO PERMIT APPLICATION FORM
APN Date:
Building Address:
0( V Ut
Owner's Name: Phone
Contractor: Phone
�,/Aj Fax#: Z 147--ks
06
Contractor icense Cupertino Business License
Contact: Phone#: Z74 �"�
el-I
Fax #:
Building Pen-nit Info:
Elect El/ Plumb � Mech
Residential 1Z Commercial
Job Description:
4, vv� a. (2, t -
For R Atial Installations:
Attic ey I"floor 2nd floor ❑
-Adhere to mim'mum setback requirement
For Commercial Installations:
AA
Replacement same weight F-1 Additional weight (structural calcs' ❑
Structural Calculations required for new installation 0
New installation Planning Approval Required 1:1
Cost of Project: Type of Construction (Usage Class):
Strapped D On Platform D Bonded E] New Location E] Replacement
Valuation:
Green Building: Must attach Green Building Cb eck list to this application
CITY OF CUPERTINO
FURNACE/AC
OF
CUPERTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit'Type
Group
FURNACE FURN/AC
1MCRAA Commercial-l,epair/Alteration/Add to M
ea heating appliance,refrigeration unit,
cooling unit,a')sorption unit,or ea
heating,coolir g,absorption or
evaporative cooling system,incl
installation of controls regulated by this
code.
1MCREPALT Commercial f Dr the repair of alt/add to M
ea heating appliance,refrigeration
unit,cooling unit,VAV boxes,
absorption un-t or ea heathing, cooling
absorption,or evaporative cooling sys,
incl install of 3ontrols regulated by
this code.
1MCSUSHTR Commercial Iastall/Relocate ea M
suspended heater,recessed wall htr, or
floor mountec unit heater.
1PGASCOM Commerical for ea gas piping System P
1-4 outlets
1BPGAS For each gas piping system of 5 or P
more per outl(A.
1MCAPPVNT Commercial for the install/relocate/ or M
replacement c f ea appliance vent
installed &nc t incl in an appliance
permit.
1BSE1TSMiC0 Commercial Seismic B
11V1RRAA Residential R,-pair/Alteration/Add to M
ea heating appliance,refrigeration unit,
cooling unit,absorption unit,or ea
heating,coolii ig,absorption or
evaporative cooling system,incl
installation of controls regulated by
this code.
1MRSUSHTR Residential Ir.stall/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted unit heater.
1MRAPPVNT Residential fcr the install/relocate/or M
replacement c,f ea appliance vent
install ¬ incl in an a pl permit.
CITY OF CUPERTINO
FUWr ACE/AC
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
FURNACE FITRN/AC
-1PGASRES ResideRial-fo`rea gas piping system of- P
1-4 Outlets
1BPGAS For each gas piping system of 5 or P
more per outle-..
/ 1BSEISMICR Residential Se:smic B
1MECPLNCK Mechanical Plin Check M
1MFR=<100 Furnace Syst<==100k BTU install or M
relocate ea for,,ed-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance up to and
include 100,000 Btu/h
1MFRN>100 Furnace Syst 100k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance over
100,000 Btu/b
1EPERMITFEE Electric Permit Fee E
1MPERMITFEE Mechanical Pormit Fee M
1PPERMITFEE Plumbing Permit P
1TRAVDOC Travel Documentation B
1BUSLIC Business License B
CITY OF CUPERTINO �
FURNACE/AC
CITY,UPEI�TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
AIR FURN/AC
CONDITIONING
1BCAIRHAN Commercial A/C Jnits <= IOk CFM B
1 MCRAA Commercial Mech Repair/alt/add M
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Seismic Commercial B
1 PGASCOM Commerical for ea gas piping System P
1-4 outlets
1 PGASRES Residential for ea gas piping system P
of 1-4 Outlets
1 BPGAS For each gas piping system of 5 or P
more per outlet. C omm/Resid
1BREMAIRHAN Residential A/C units <= IOk CFM B
1 MRRAA Residential Mech Repair/alt/add M
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
1 EPERMITFEE Electric Permit E
1 MPERMITFEE Mechanical Perm-t M
1 PPERMITFEE Plumbing Permit P
1 TRAVDOC Travel Documentation B
1BUSLIC Business License B