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09110135 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10171 CARMEN RD CONTRACTOR:NORTH CAL HEATING PERMIT NO:09110135 AND AIR NER'S NAME: DIRK BARTELS 10216 PASADENA AVE DATE ISSUED: 11/23/2009 OWNER'S PHONE: 4084838455 CUPERTINO,CA 95014 PHONE NO:(408)446-1702 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG f— ELECT PLUMB License Class U Lic.# ( � TJ S' MECH f- RESIDENTIAL f- COMMERCIAL Contractor " tMi Date Q I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE GAS FURNACES (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:$1300 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:3 570110 1.00 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: Date: 9.18. / / ture �`�J`4-c� "4 Date 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) 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 permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the 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 Ow . $�th�gent: _� ? Compensation laws of California. If,after making this certificate of exemption,I y/ �- 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 affinn 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 hnilding construction,and hereby authorize representatives of this city to enter Lender's Address he above mentioned property for inspection purposes.(We)agree to save u _.unify and keep harmless the City of Cupertino against liabilities,judgments, costs,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. Licensed Professional Signature Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN 35701101 . 00 DATE ISSUED. . . . . . . : 11/23/2009 RECEIPT #. . . . . . . . . : BS000009266 REFERENCE ID # • . . : 09110135 SITE ADDRESS . . . . . : 10171 CARMEN RD SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER DIRK BARTELS ADDRESS 10171 CARMEN RD CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-2759 RECEIVED FROM . . . . : NORTHCAL HEATING &A CONTRACTOR . . . . . . . : SLOBODAN PLAVSIC LIC # 30551 COMPANY NORTH CAL HEATING AND AIR ADDRESS 10216 PASADENA AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . : (408) 446-1702 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 1, 300 . 00 1. 00 0 . 00 1. 00 0 . 00 1BSEISMICR VALUATION 1, 300 . 00 0 .50 0 . 00 0.50 0 . 00 1EPERMITFE FLAT RATE 1. 00 42 . 00 0 . 00 42 . 00 0 . 00 1MPERMITFE FLAT RATE 1. 00 42 .00 0 .00 42 . 00 0 . 00 1MRRAA UNITS 1. 00 63 .00 0 .00 63 . 00 0 . 00 1PPERMITFE FLAT RATE 1. 00 42 . 00 0.00 42 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 190 .50 0. 00 190 . 50 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 190 .50 #242 --------------- TOTAL RECEIPT 190 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL City OF CITY OF CUPERTINO IM FURNACE/AC C U P E RT I N O PERMIT APPLICATION FORM APN # Date: t' D I l o Buildi g Address: 101-7/ C eN . Owner's Name: Phone#: A-JL Contractor: Phone#: N Fax#: 44::W— —s'o1 Contractor License#: Cupertino Business License#: 3as-5I Contact: Phone#:U c- 0 83 8�-SS— Fax#: Building Permit Info: Elect� Plumb [ � Mech Residential bQ Commercial ❑ Job Description: J4_--?_ tAC 0 S AN L!S For Residential Installations: Attic ❑ 1St floor liq 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: 1100 Type of Construction (Usage Class): (�,/ 0 Strapped ❑ On Platform ❑ Bonded ❑ New Location El ReplacementICY 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 CITY OF CUPERTINO is FURNACE/AC CUPERTINO FEE SCHEDULE floor mounted unit heater. Quantity Fee ID Fee Description Fee Permit Type Group 1MRAPPVNT Residential for the install/relocate/or M replacement 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. / 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1 BSEISMICR Residential Seismic B 1MECPLNCK Mechanical Plan Check M 1MFR=<100 Furnace Syst<=100k BTU install or M relocate ea forced-air/gravity type furnace/bumer, incl ducts/vents attached to such appliance up to and include 100,000 Btu/h IMFRN>100 Furnace Syst> 100k 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 I 1MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE Plumbing Permit P 1TRAVDOC Travel Documentation B Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 .;UPEI�TINO Building Department JOB ADDRESS: J o �► 'j?-b PERMIT # CAATN-- ?'l NO CA- f1 S0 CA t ( c� ( 3�_ OWNER'S NAME: D I eC- PHONE # – .S'% GENERAL CONTRACTOR:/J 02rH CJtL FAX # 439 �' aZ 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 L/ Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile -6tnA� // Owner/Contractor Signature Date