09110008 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20278 NORTHWEST SQ CONTRACTOR:A&A PLUMBING PERMIT NO:09110008
OWNER'S NAME: KENNETH ONEILL 1030 E EL CAMINO REAL STE 248 DATE ISSUED: 11/02/2009
IER'S PHONE: 4089963120 SUNNYVALE,CA 94087 PHONE NO:(408)738-8878
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE WATER HEATER,FURNACE/AC
(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 Sq.Ft Floor Area: Valuation.$2500
performance of the work for which this permit is issued.
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 APN Number:20278 NORTHWEST SQ Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180LYS YS FRO ASTCALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the /
granting of this permit. Additionally,the applicant understands and will comply Issued b ! Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Signature Date
RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
OWNER-BUILDER DECLARATION installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: Signature of Applicant: Date:
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE
1 hereby affirm under penalty of perjury one of the following three I have read the hazardous materials requirements under Chapter 6.95 of the
declarations: California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain a Certificate of Consent to self-insure for Worker's compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should 1 store or handle hazardous material.
performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air
1 have and will maintain Worker's Compensation Insurance,as provided for by 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
Section 3700 of the Labor Code,for the performance of the work for which this Health&Safe Cod Sections 25505,25533,and 25534.
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall or au zed
not employ any person in any manner so as to become subject to the Worker's ate: 4511
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 CONSTRUCTION LENDING AGENCY
forthwith comply with such provisions or this permit shall be deemed revoked. I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued(Sec.3097,Civ C.)
APPLICANT CERTIFICATION Lender's Name
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 Lender's Address
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
mify and keep harmless the City of Cupertino against liabilities,judgments,
and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.l 8.
Signa Date
CITY OF CUPERTINO
8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 20278 NORTHWEST SQ
DATE ISSUED. . . . . . . : 11/02/2009
RECEIPT #. . . . . . . . . : BS000009102
REFERENCE ID # . . . : 09110008
SITE ADDRESS 20278 NORTHWEST SQ
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER KENNETH O'NEILL
ADDRESS 20278 NORTHWEST SQ
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : KENNETH W O'NEILL
CONTRACTOR MIKE FOX LIC # 25401
COMPANY A & A PLUMBING
ADDRESS 1030 E EL CAMINO REAL STE 248
CITY/STATE/ZIP . . . : SUNNYVALE, CA 94087
TELEPHONE (408) 738-8878
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 2, 500 . 00 1 .00 0 . 00 1. 00 0 . 00
1BSEISMICR VALUATION 2, 500 . 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
1PRWHEATR UNITS 1. 00 25 . 00 0 .00 25. 00 0 . 00
1TRAVDOC FLAT RATE 1. 00 42 . 00 0. 00 42 . 00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 257 .50 0 . 00 257. 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 257 .50 #1461
---------------
TOTAL RECEIPT 257 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
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CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN # '�)/ ( _ (D Date:
3 9Building Address:
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Building Permit Info:
Elect ❑ Plumb Mech
Residential Commercial ❑
Job Description:
For Residential Installations:
Attic [--I1sc 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):
/ 70 o fid.
Strapped On Platform Bonded El New Location Replacement
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 CUPERTINO
FURNACE/AC
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Grou
1MRAPPVNT Residential for the install/relocate/or M
replacement of ea appliance vent
install ¬ 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
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
1MFRN>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
I1MPERMITFEE Mechanical Permit Fee M
1PPERMITFEE Plumbing Permit P
I1 TRAVDOC Travel Documentation B
1 BUSLIC Business License B