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09120091 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10256 VIRGINIA SWAN PL CONTRACTOR:A&H HEATING PERMIT NO:09120091 OWNER'S NAME: FUREY THOMAS H AND TERI E 770 CHESTNUT ST DATE ISSUED: 12/15/2009 4ER'S PHONE: 4082572623 SAN JOSE,CA 95110 PHONE NO:(408)279-0722 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class —47P Lic.# C,( f-W [-MECH RESIDENTIAL COMMERCIAL r Contractor Date l I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE&REPLACE FURNACE&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: 1 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:$7600 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:31646001.00 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 /9 with all non-point source regulations per the Cupertino Municipal Code,Section Issued byr�� "� Datet',2 s 9.18. Signature to 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: 1,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). 1 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. 1 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 permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the p 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 Qffyer or authorized ag /Z / t Compensation laws of California. If,after making this certificate of exemption,I ! J 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.) 1 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 ur-n the above mentioned property for inspection purposes.(We)agree to save nify and keep harmless the City of Cupertino against liabilities,judgments, cb—,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION 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. � ` A Licensed Professional Signatu Date CITY OF CUPERTINO FUF24ACE/AC CUPE(�TINO PERMIT APPLICATION FORM APN # Date: 4 (, c) � � I o,, Building Address:`DZ 5-& v` f�/, 11J1 r/� `5t01 ` PL. Owner's Name l��tT' 17 /T!v r Phone#: r aau F-vg:Ey X88 z-5 7-2-6Z3 Contractor: If Phone#:,%o$ Z7 9- d?ZZ Fax#: If 05 Z?g-1017 Contractor License M Cupertino Business License#: ®ct4-Z Z Contact: Phone#: t fOg 2,?g �7� �� Pff `� Fax #: Building Permit Info: Elect Plumb Mech Residential ET Commercial ❑ Job Description: For Residential Installations: Attic ❑ ls` floor 2r 2nd 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: 7&VO TO Type of Construction (Usage Class): �/lf� Strapped El On Platform Bond,-d New Location ❑ Replacement Project Size: Express [ -Standard ❑ Large D 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 C'UPERTINO ` FURNACE/AC CUPEkTiNO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group FURNACE FURN/AC 1 MCRAA Commercial-Rep air/Alteration/Add to M ea heating appliance,refrigeration unit, cooling unit,abso-ption unit,or ea heating,cooling,a)sorption or evaporative cooli:lg system,incl installation of controls regulated by this code. 1 MCREPALT Commercial for t-ie repair of alt/add to M ea heating appliwice,refrigeration unit,cooling unit,VAV boxes, absorption unit or ea heathing, cooling absorption,or eva jorative cooling sys, incl install of controls regulated by this code. 1 MCSUSHTR Commercial InstE.11/Relocate ea M suspended heater.recessed wall htr, or floor mounted unit heater. 1PGASCOM Commerical for ea gas piping System P 1-4 outlets 1 BPGAS For each gas piping system of 5 or P more per outlet. 1MCAPPVNT Commercial for tie install/relocate/ or M replacement of ea appliance vent installed &not in-1 in an appliance permit. 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICO Commercial Seismic B 1MRRAA Residential Repair/Alteration/Add to M ea heating appliarice,refrigeration unit, cooling unit,absorption unit,or ea heating,cooling,absorption or evaporative cooli:ig system,incl installation of cor.trols regulated by this code. 1 MRSUSHTR Residential Instal./Relocate ea M suspended heater,recessed wall htr, or floor mounted un:t heater. CITY OF C UPERTINO FURNikCE/AC CUPEkTINO FEE SCJKEDULE Quantity Fee ID Fee Description Fee Permit Type Group AIR FURN/AC CONDITIONING 1 BCAIRHAN Commercial A/C Units <= l Ok CFM B 1MCRAA Commercial Mech Repair/alt/add M 1BCBSC Cal Bldg Standar,is Commission Fee B ALL PERMIT TYPES 1BSEISMICO Seismic Commer-,ial B 1PGASCOM Commerical for ca 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 piling system of 5 or P more per outlet. Comm/Resid 1 BREMAIRHAN Residential A/C units<= 10k 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 1MPERMITFEE Mechanical Permit M 1 PPERMITFEE Plumbing Permit P 1TRAVDOC Travel Documentation B 1BUSLIC Business License B Community Development 10300 Torre Avenue ' % ` Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 LUPERTINO Building Department JOB ADDRESS:/ 'CIALPERMIT # 6cel �Q/2 D 6 Q OWNER'S NAME: � = PHONE — Z GENERAL CONTRACTORFAX # Z? — 6 I am not using any subcontractors: ` l S 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 Rock Tile 6 Owner/Contractor Signature Da