09120108 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10471 HENEY CREEK PL CONTRACTOR:QUAN'S ELECTRICAL PERMIT NO:09120108
OWNER'S NAME: LEE DICK T AND SOPHIE S 10628 RANDY LN DATE ISSUED: 12/17/2009
YER'S PHONE: 6507628185 CUPERTINO,CA 95014 PHONE NO:(408)366-1823
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class (�w,C_-&O Lic.# 2U 1� S—r Z
MECH RESIDENTIAL COMMERCIAL
Contractor Date )Zr,
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE FURNACE
(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:$4800
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
permit is issued. APN Number:34248014.00 Occupancy Type:
APPLICANT CERTIFICATION
1 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" -/�
Date•
9.18.
Signature Date
RE-ROOFS:
Lr 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 1 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
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.
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 Owner or aut orized agent:
Compensation laws of California. If,after making this certificate of exemption,I Date: 1 0
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
i nify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
C ,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
YL
FURNACE/AC
CUPEkTiNO PERMIT APPLICATION FORM
APN # �, - ( Date: r Z
BuildiAddress:
n
Owner's Name: Phone`#: r-.
Contractor. Phone#:
h 41 62 ev'i Fax#:
Contractor License#: Cupertino Business License#:
-76 r�
Contact: Phone#: j�C
CtA 61 t Fax #:
Building Permit Info:
Elect Plumb - Mech LV
Residential a Commercial ❑
Job Description:
For Residential Installations:
Attic ❑ I" floor 2°d 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 ❑
Cost of Project: Type of Construction (Usage Class):
Strapped H On Platform ❑ Bonded=_
onded New Location LJ Replacement
Project Size: Express Q,--Standard ❑ Large [I 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.
I
Revised 01/07/09
CITY OF CUPERTINO
a FURNA.CEAC
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
FURNACE FURN/AC
1 MCRAA Commercial-Repz.ir/Alteration/Add to M
ea heating appliar.ce,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,at)sorption or
evaporative cooling system,incl
installation of controls regulated by this
code.
1 MCREPALT Commercial for the repair of alt/add to M
ea heating appliar..ce,refrigeration
unit,cooling unit,`/AV boxes,
absorption unit or ea heathing, cooling
absorption,or evaporative cooling sys,
incl install of con-xols regulated by
this code.
1MCSUSHTR Commercial Install/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted un:t heater.
1PGASCOM Commerical for ea gas piping System P
1-4 outlets
1BPGAS For each gas piping system of 5 or P
more per outlet.
1MCAPPVNT Commercial for the install/relocate/ or M
replacement of ea appliance vent
installed ¬ in-,I in an appliance
permit.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Commercial Seis:nic B
lMRRAA Residential Repair/Alteration/Add to M
ea heating appliance,refrigeration unit,
E cooling unit,abso-ption unit,or ea
heating,cooling,a:)sorption or
evaporative cooling system,incl
installation of controls regulated by
this code.
1MRSUSHTR Residential Install/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted unit heater.
CITY OF CUPERTINO
FURN-ACE/AC
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Descripti:)n Fee Permit Type
Group
1 MRAPPVNT Residential for the install/relocate/or M
replacement of ea appliance vent
install ¬ in,-,I in an appl permit.
FURNACE FURN/AC
1 PGASRES Residential for ea gas piping system of P
1-4 Outlets
1 BPGAS For each gas piping system of 5 or P
more per outlet.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Residential Seismic B
1 MECPLNCK Mechanical Plun Check M
1MFR=<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 Syst> 100k BTU install or M
relocate ea forged-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance over
100,000 Btu/h
1 EPERMITFEE Electric Permi:Fee E
j 1MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit P
1
1TRAVDOC Travel Documentation B
1BUSLIC Business License B
Community Development
µ" 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
.;UPEkTINO
Buildi�n De artment
0 e-
JOB ADDRESS: PERMIT #
G'G-,=7 �'a-t�, C� ��2�f
OWNER'S NAME: i C r PHONE # �. %Tr
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date ,
Please check applicable 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 �, C'.
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
_ '�It 7 0
Owner/Contractor Signature Date