13080012 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10372 SCENIC CIR CONTRACTOR:'(jOv rn/VL PERMIT NO: 13080012
A/4 h1/2 dOA)12.
OWNER'S NAME: ISBELL TIM D AND ROBERTA J DATE ISSUED:08/02/2013
OWNER'S PHONE: 4082576590 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 0 COMMERCIALE1
License Class ``)-6 Lie.# 4e o& REPLACE(E)FURNACE,SAME LOCATION&ADD(N)A/C
MA-L / T S,,Da UNIT IN SIDE YARD AREA
Contractor l��r'�!' '�—c�y"13
I hereby affirm that I am licensed under the provisions of Chapter 9
(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:$13000
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
APN Number:35707025.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I 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 DA T 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 180 DA M L LLED INSPE�Tlr,N.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ccosts,and expenses which may accrue against said City in consequence of theoZ
granting of this permit. Additionally,the applicant understands and will comply Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
/ RE-ROOFS:
Signature _14 L ✓ _ Dateg`r�4—13 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
inspection.
13O ER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I.hereby affirm under penalty of perjury one of the following three 'maintain compliance with the Cupertino Municipal Code,Chapte9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Section 25505,25533,and 2553_4.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: 1 CGw,'� Date:
permit is issued.
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
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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
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
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,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
9.18.
Signature Date
n /
GENERAL PERMIT APPLICATION �` v
b MEP
Lo COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•building(Wcupertino.org misc
❑PLUMBING 8 MECHANICAL ❑ELECTRICAL [:]MISCELLANEOUS
PROJECT ADDRESS D se o N I i TPN# S D
i
OWNER NAME E-MAIL
STREET ADDRESS �7 CITY,STATE,ZIP FAX
CONTACT NAMEL. J� CL�iI�Cr�S7F•1��1
STREET ADDRESS CITY, ATE,ZJ�e, /,.' c /FAX��
❑OWNER 11OWNER-BUILDER ❑ OWNERAGENT 11 CONTRACTOR El CONTRACTOR AGENT ARCHITECT ❑ENGINEER 3❑ DEVELOPER ❑ TENANT
CONTRA OR NAME LICEN LICiENSE TYPE BUS.LIC#
�ERL`r�d
COMPA�rY NAME �MAII t FAX
(��N-rO--V►L i% �,IL ('2��7'kAL� lei,l2. ,:Ii C,�s'� �`t
STREET ADDj SS Y,STATE,Z / i PHO
601
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WHALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK n
FU)ZN Ace n iUb A D tJ 1-� C� (.i N I i�✓I � CD'
e ( 6"Aoil
TOTAL VALUATION: REC
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to#ding construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: 1 Date:
IFPLE TAL INF RMATION REQUMD OFFICE USE ONLY
w VER-THE-COUNTER
EXPRESS
El U
STANDARD
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❑ LARGE
El a
MAJOR
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
x ADDRESS: 10372 SCENIC CIR DATE: 08/02/2013 REVIEWED BY: MELISSA
APN: 357 07 025 BP#: *VALUATION: 1$13,000
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: p PERMIT TYPE:
WORK REPLACE E FURNACE SAME LOCATION &ADD N A/C UNIT IN SIDE YARD AREA
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
A/C Units (<=10K cfm) 1BREMAIR 1 # $70
Furnace, Forced-Air 1MFR=<100 1 # $139
TOTALS: $209.00 0
Mech.Plan Check 0.0 hr71,AVPERAff
Phvub.Plan Check Elec.Plan Check
Mech.Permit FePlumb.Permit Fee: (glee. Permit Fee:
Other Mech.Insp. 0.0 hrQther Plumh Insp, E3
tither Elec.Insp.
1/ech.Insp.Fee: Plumb. hrsp.Fee: Elec.Insp.Fere:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These ees are based on the prelimina information available and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
S'uppL PC.'Fee
PME Plan Check: $0.00
.Permit Fee:
Supp 1. Insp Fee
PME Unit Fee:. $209.00
PME Permit Fee: $47.00
Conoraction Tax:
Administrative Fee: IADMN $44.00
Work Without Permit? ®Yes (j) No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRAVDOC $47.00
Strang Motion Fee: IBSEISMICR $1.30 Select an Administrative Item
Bldg:Stds Commission Fee: IBCBSC $1.00
;4
$349.30 $0.00 $349.30
O . �
t�(Revised: 07/01/2013
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ENT
COMMUNITY DEVELOP ENT DEPARTMENT
J
BUILDING DIVISIO -CUPERTINO
AppROVED PSI CUpEINO
This set of plans and specific Building De ,artment
job s11,16 during construction. it is unlawful to make any
ions on same,or to deviate
changes or alte-rata
without approval from the BuildingOfficial. . ,
AUG� O 2G13
therefrom,
The stamping of this plan and specifications SHALL NOT EwEp FUR CODE COtv1PLIANCE
b;;held to ermit or to be an approval of the violation REVI
n revisions ity Ordinance or State Law.
Reviewed By:
BY I
DATE —
PERMIT NO.
5c.0e: "�KeTyC �
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