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09120112 (2) CITY OF CUPERTIN O BUILDING PERMIT BUILDING ADDRESS: 20288 PACIFICA DR CONTRACTOR:AAA FURNACE&AIR PERMIT NO:09120112 CONDITIONING 'gER'S NAME: VIRGINIA MICKELSON 1712 STONE AVE DATE ISSUED: 12/18/2009 OWNER'S PHONE: 4082527425 SAN JOSE,CA 95125 PHONE NO:(408)2934717 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F ELECT f- PLUMB License Cl /.C-td Lic.# :?U k7 7 / r- r- r MECH RESIDENTIAL COMMERCIAL Contractor �Date1_ lk-6 I hereby a u•m that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE EXISTING UNITE,INSTALL NEW 4 TON HEAT PUMP (commencing with Section 7000)of Division 3 of the Business&Professions &AIR HANDLER IN SAME LOCATION Code and that my license is in full force and effect. 1 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. 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 Sq.Ft Floor Area: Valuation:$10600 permit is issued. APPLICANT CERTIFICATION APN Number:36944011.00 Occupancy Type: 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 to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses whic ay accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this perm'. Ad Wally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all int urce r ations per the Cupertino Municipal Code,Section 9.18. ,At-6 Issued hy: -'�7J Date: ,ature Date V / ❑ OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defin by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain co nc th the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's S ety e,Sections 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,I must Own r or rized agent: )L���-0� forthwith comply with such provisions or this permit shall be deemed revoked. Date: CON TRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) +�building construction,and hereby authorize representatives of this city to enter Lender's Name n the above mentioned property for inspection purposes.(We)agree to save ._.,,emnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address costs,and expenses which may accrue against said City in consequence of the granting of this pen-nit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional 09 to CITY OF CUPERTINO FURNACE/AC CUPEkTINO PERMIT APPLICATION FORM APN # , 44 + ` Date: r C Building Address: ap ]a-SS, T) CtC i f i'tA t72 Owner's Name: v rC� i N�' IAA I,L l,` r 1 S e-,Al Phone#: 4.0 -as-- - 7-J z.s— Contractor: G J/:.1 C- /"V c Phone#: 4 ok -373 _ Y 7 I}- +r''°a" Fax #: 4-0k—,323 -(,p '7-7t Contractor License#: -7 (,k-" , — <Lq 5 /LZ_(j Cupertino Business License#: Contact:C,G 2 Y TC W Z P/- Phone #: 4-01--meq;j -6/ 7 i Fax #: Q-v k (o7 -7i Building Permit Info: Elect [C]/ Plumb Mech Residential E0111 Commercial Job Description: Qe(.oV-e p ic,s4 rimer n,`f 1►v� 4- A.R Pu nel 1,er ¢roti For Residential Installations: Attic ❑ l" floor 2"d floor ❑ Adhere to minimum setback requirement []� For Commercial Installations: Replacement same weight ❑ Additional weight (structural calcs) ❑ Structural Calculations required for new installE tion ❑ New installation Planning Approval Required [] Cost of Project: /©, 66,0.p d Type of Construction (Usage Class): Strapped 77 On Platform Bonded New Location Replacement Project Size: Express ❑ Standard ❑ Large ❑ Major ❑ Valuation: l0) 6,00- 00 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 FURNACE/AC CUPERTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group FURNACE FURN/AC 1 MCRAA Commercial-Repair/Alteration/Add to M ea heating appliance,refrigeration unit, cooling unit,absorption unit,or ea heating,coolin;,absorption or evaporative ccoling system,incl installation of controls regulated by this code. 1 MCREPALT Commercial for the repair of alt/add to M ea heating appliance,refrigeration unit,cooling unit,VAV boxes, absorption uni t or ea heathing, cooling absorption,or evaporative cooling sys, incl install of controls regulated by this code. 1 MCSUSHTR Commercial Iristall/Relocate ea M suspended heater,recessed wall htr, or floor mounted unit heater. 1 PGASCOM Commerical for ea gas piping System P 1-4 outlets 1BPGAS For each gas piping system of 5 or P more per outlet. 1 MCAPPVNT Commercial for the install/relocate/ or M replacement of ea appliance vent installed & nol incl in an appliance permit. 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES I BSEISMICO Commercial S,;ismic B 1 MRRAA Residential Repair/Alteration/Add to M ea heating app:iance,refrigeration unit, cooling unit,ab sorption unit,or ea heating,cooling,absorption or _ evaporative co sling system,incl installation of,;ontrols regulated by this code. 1 MRSUSHTR Residential Install/Relocate ea M suspended heal er,recessed wall htr, or floor mounted unit heater. CITY OF CUPERTINO =' FURNACE/AC CUPEkTINO FEESCHEDULE Quantity Fee ID Fee Des,:ription Fee Permit Type Group 1MRAPPVNT Residential for the install/relocate/or M replacem-.nt of ea appliance vent install & not incl in an appl permit. FURNACE FURN/AC 1PGASRES 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. 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Residential Seismic B 1 MECPLNCK Mechanical Plan Check M 1 MFR=<100 Furnace �yst<=100k BTU install or M relocate ea forced-air/gravity type furnace/b.imer, incl ducts/vents attached tD 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/blimer, incl ducts/vents attached t:) such appliance over 100,000 Eitu/h 1 EPERMITFEE Electric Permit Fee E 1MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE Plumbing Permit p t 1TRAVDOC Travel Documentation B 1BUSLIC Business License B CITY OF CUPERTINO FURNACE/AC CUPEkTINO FEE '15CHEDULE Quantity Fee ID Fee Description Fee Permit Type Group AIR FURN/AC CONDITIONING 1 BCAIRHAN Commercial A/C Units <= 1 Ok CFM B 1 MCRAA Commercial Mech Repair/alt/add M 1BCBSC- Cal Bldg Staidards Commission Fee B ALL PERMIT TYPES 1BSEISMICO Seismic Corrmercial 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 Outlet 1 BPGAS For each gas piping system of 5 or P more per out:et. Comm/Resid 1 BREMAIRHAN Residential AJC units <= l Ok CFM B / 1 MRRAA Residential hlech Repair/alt/add M 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1 BSEISMICR Seismic Residential B I EPERMITFEE Electric Perrr it E 1 MPERMITFEE Mechanical F ermit M 1 PPERMITFEE Plumbing Permit P 1TRAVDOC Travel Documentation B 1BUSLIC Business Liccrise B Mnooir tr Quality and Finishes 1.iiset oMO-VOC wtg 1 IAQ/Health pts y=yes 0 2.Use Low VOID,Water-Based Wood Finishes 2 IAQ/Health pts y--yes 0 3.Use Low/No VOC Adhoslves 3 IAQ/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 Formaldehyde 61AQ/Hsalth pts y=yes 0 0 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y--yes 41AQ/Health. pts y=yes 0 8.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0 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 1 N.Flooring 1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0 2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 0 3,Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0 4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 0 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 1 Total Points Available� 1 1401 130 57 Total Points Project Receive;] 01 01 0 G:daWprc3s/greenbuil nes/remodelersrgreenpointsfina1212.04protected.zls Community Development f. 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 �UPEkTINO Building Department JOB ADDRESS: PERMIT# ego 2's S- c COWNER'SNAME: V/ )A'-\ W i c K el5c ,� PHONE #4�j 2 Z - 7cl 2 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 Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Fpc Tile 1 Z _4- ' Date er/Contractor S' afore