09110133 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21597 FLINTSHIRE ST CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO:09110133
OWNER'S NAME: JESS&PAM MARINO DATE ISSUED: 11/23/2009
ER'S PHONE: 4088650733 , PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT f- PLUMB
License Class C L.,.# � Ff—
MECH RESIDENTIAL COMMERCIAL
Contractor SA 1+6 6166, WO A trate l �23 01
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:FURNACE REPLACEMENT IN CLOSET IN LIVING ROOM
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 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:$3000
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:35620053.00 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 constriction,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
p �'lip p p Issued by: ..•••'' Date
9.18.
Signature Date i 1 12- 16/1
RE-ROOFS:
G 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 stricture 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. 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 1 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
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's Owner or author' a it:
Compensation laws of California. If,after making this certificate of exemption,I Date: (1 'L 3!
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 constriction 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
nify and keep harmless the City of Cupertino against liabilities,judgments,
L ,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
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35620053 .00
DATE ISSUED. . . . . . . : 11/23/2009
RECEIPT #. . . . . . . . . : BS000009263
REFERENCE ID # . . . : 09110133
SITE ADDRESS . . . . . : 21597 FLINTSHIRE ST
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER JESS & PAM MARINO
ADDRESS 21597 FLINTSHIRE ST
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4715
RECEIVED FROM . . . . : S A HEATING & AIR C
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 3, 000 . 00 1 . 00 0. 00 1. 00 0 . 00
1BSEISMICR VALUATION 3, 000 . 00 0 .50 0. 00 0.50 0 . 00
1BUSLIC FLAT RATE 1 . 00 114 . 00 0. 00 114 . 00 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 304 .50 0 . 00 304 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 304 .50 VISA
---------------
TOTAL RECEIPT 304 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
CITY OF CUPERTINO
slli�� FURNACEAC
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1 MRAPPVNT Residential for the install/relocate/or M
replacement of ea appliance vent
install ¬ incl 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
I 1BSEISMICR Residential Seismic B
I
1 MEC LNCK Mechanical Plan 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> l 00k 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
1 MPERMITFEE Mechanical Permit Fee M
1PPERMITFEE Plumbing Permit P
1 TRAVDOC Travel Documentation B
i 1 BUSLIC Business License B
Community Development
10300 Torre Avenue
b_UMV;
V Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
,XPEI�TINO
Building Department
JOB ADDRESS: PERMIT #
, � i�; �� 5 `tel � I o13 �
OWNER'S NAME:J-e s ; $ ( go v, (V 0. ; vL PHONE # (9 l y Z 82 :7'10)
GENERAL CONTRACTOR: A AEA T I N A jRN D A 1 V_ FAX # (q t 2. -4 0'2-
I
.ZI am not using any subcontractors: -
Si "ature Date
Please check applicable subcontractors and complete the following information:
60 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
•t Z 3 d�
OwneContr ct Signature Date