13100002 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20124 NORTHWIND SQ CONTRACTOR:A&H HEATING PERMIT NO:13100002
OWNER'S NAME: KNOESPEL,INGE 770 CHESTNUT ST DATE ISSUED:10/01/2013
OWNER'S PHONE: SAN JOSE,CA 95110 PHONE NO:(408)279-0722
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL
License Class e—2 0 Lia# %6t4C 7 Z REMOVE AND REPLACE FURNACE AND A/C IN SAME
�� �- LOCATION
Contractor 1�1 � 1�n-fi Date �t^/3
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
erformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$5200
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:31638053.00 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 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 180 DAYS O LAST CALLED 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 by: Date: a L,��eI3
with all non-point source regulations,per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signatu Date .Pi—r^f5 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.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
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)
I,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,Chapter 9.12 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,Sectio 5505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this G.-e--J
permit is issued. Owner or authorized agent Date
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
GENERAL PERMIT APPLICATION
MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION �d
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 O
CUPERTINO (408)777-3228•FAX(408)777-3333•building a2cupertino.or. \ MISC
[]PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS 276 12 J /� n (ap APN# 31 r „ '2>
OWNER NAr- -A/6,, -2; L(O Los W�L►- `1P f 9b a q L g- 0U CJlyC I
E-MAIL �J
STREET ADDRESS 2CJ (/ n CI I, /_ C ST ^ A_.7fa FAX
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CONTACT N�f T" ' l �/ P� /7 2_'yim E-MAIL
STREET ADDRES//S)6 ITY TtfOZY1s FAX
J i`J V u 1
❑OWNER ❑ OWNER-BUELDER ❑ OWNER AGENT L9 CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
cONTRACTOFM1 e L $E TM Ljf `�LIrS€Tc BUS. C2O
COMPANYM E-MAIL ( w FAX
STREET ADDRM-7 �i �T --� CITY A l ! n�y fes/ ! PH �`f -2 7_
ARCHITECT/ENGINEER NAME ' LICENSE NUMBER V `�/ U 1 BUS.LIC# > Cl-)lJ C
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD.,DUPLEX MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES rE7
BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA I2 NO FLOOD ZONE ®NO R HOME? $NO
DESCRIPTION OF WORK
TOTAL VALUATION:
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on thproperty er'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 acc rate. I a&ee to comply with all applicable local
ordinances and state laws relating to b 'Idin on. uthorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: / 1—
13
SUPPLEMENTAL INFORMATION REQUIRED F colo—,
EXP;I2ES
ARD
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 20124 NORTHWIND SO DATE: 10/01/2013 REVIEWED BY: MENDEZ
191APN: BP#: *VALUATION: 1$5,200
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION FURN/A
USE: PERMIT TYPE:
WORK REMOVE AND REPLACE FURNACE AND A/C IN SAME LOCATION
SCOPE
rK
m13
Mech.Plan Check 0.0 hrs $0.00 111,�rib� Plan(71,,ec'k 1r.
Mech.Permit Fee: IMPERMTI Fee 1'ir:r.
Other Mech.Insp. 0.0 hrs $47.00 Oi&,rT'irrmb Insp. "-Ld
C1zh r Is1r(e
y n,.h, IP[.sP. £'" £'hkmb,Imp, Fee: E.",,;'.
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer Distric4 School
District,etc.). Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addn 7 info,
FEE ITEMS (Fee Resolution 11-053 E . 7�f 113) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 # Mechanical
Suppl. PC Fee: (E) Reg. ® OTJ 0.0 hrs $0.00 $139.00 1MFR=<100 Furnace,Forced-Air
PME Plan Check: $0.00 = # Mechanical
Permit Fee: $0.00 $70.00 IBREMAIR A/C Units (<=1OK cfm)
Suppl. Insp.Feer Reg. 0 OT O O hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $47.00
Administrative Fee: IADMIN $44.00 0
Work Without Permit? 0 Yes No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential
Travel Documentation Fee: ITRAVDOC $47.00 Building or Structure
Strong Motion Fee: IBSEISMICR $0.52 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
, ter y $139.52 $209.00 $348.52
a, S ' TOTAL FEE:
Revised: 08/01/2013