13100003 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1123 MILKY WAY CONTRACTOR:A&H HEATING PERMIT NO:13100003
OWNER'S NAME: SEROUSSI GADIEL AND LIDIA S 770 CHESTNUT ST DATE ISSUED: 10/01/2013
OWNER'S PHONE: 4082579663 SAN JOSE,CA 95110 PHONE NO:(408)279-0722
LICENSED CONTRACTOR'S.DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIAL
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License Class 2G Lie.# 3 O�l�l7 REMOVE AND REPLACE FURNACE
Contractor Datel L, "
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:$3800
I have and will maintain Worker's Compensation Insurance,as provided for by
ection 3700 of the Labor Code,for the performance of the work for which this APN Number:36219017.00 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 WIT 80 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 D FROM 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 theY-Z Z:?4
granting of this permit. Additionally,the applicant understands and will comply Issued by Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
—! ROOFS:
Signature Date any r
All roofs shall be inspected prior to y 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
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)
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,Sections 255 25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: • �i!
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 inconsequence 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.
Signator Date
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 0
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 \�
CUpERT{NO (408)777-3228•FAX(408)777-3333•building(�cupertino.org MISC
❑PLUMBING ❑MECHANICAL []ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS /113 r m�'G L APN# l I O r
OWNER NAME & ,�^l dC.L) n �j ��r� PH" -776
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STREET ADDRESS J�Z� �jk_'/nAt. `�LV C STATE,ZIP •(�� FAX
CONTACT / PHpI�jE__`S S � (f;7 (717 E-MAIL
STREETADDR C`^0A �- �J�{j- CITY, G( W_4 FAX
❑OWNER 11OwNER-BUILDER El OWNER AGENT I*CONTRACTOR ❑CONTRACTOR AGENT 11 ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
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ARCHITECT/ENGINEER NAME / J J LICENSE NUMBER v V v BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX MULTI-FAMILY PROJECT IN WI DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING. ❑COMMERCIAL URBAN INTERFACE AREA 13 NO FLOOD ZONE NO EICHLER HOME? [}NO
DESCRIPTION OF WORK
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TOTAL VALUATION: RECEIVER ��
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By my signature below,I certify to each of the following: I am the property owner or authorized agent to act A the pr erty owner's behalf. I have read this
application and the information I have pro ided is correct. I hav a Description of Work and verify it is accura e. I agree to comply with all applicable local
ordinances and state laws relating to b ' ng construct' . a rze representatives of enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: �� l
UPPLEMENTAL INFORMATION REQUIRED Fc ilsEQvL WOMAN__
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MEPMiscApp_201 Ldoc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 1123 MILKY WAY DATE: 10/01/2013 REVIEWED BY: MENDEZ
APN: BP#: *VALUATION: 1$3,800
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: PERMIT TYPE:
WORK REMOVE AND REPLACE FURNACE
SCOPE
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11� IN
0 101.
Mech.Plan Check 1 0.01 hrs $0.00 1'lurr l). I'lla r C ke'c� r'.>lu<:.I't<rrt( c c:t.
Mech.Permit Fee: IMPERMIT 1.,,¢;r,1). /'er•tr°it Fe"',
Other Mech.Insp. 0.0 hrs $47.00 OtherT'orfs Ins.p, (Jt?aer Elec.lrsF;. Li
his,,). hl'e, 1''l7df.b,Imp, Fee.- Elec, /r,sp> /,,--
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info,
FEE ITEMS(Fee Resolution 11-053 E . ZI 13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 � # Mechanical
Suppl.PC Fee: (E) Reg. 0 OT 0.0 hrs $0.00 $139.00 IMFR=<100 Furnace,Forced-Air
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee:Q Reg. ® OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $47.00
Administrative Fee: 1ADMIN $44.00 0
Work Without Permit? 0 Yes (D No $0.00 0
Advanced Planning Fee: $0.00 Select a Non-Residential
Travel Documentation Fee: 1 MVDOC $47.00 1
Building or Structure 0
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
& . A �. ,
TOAE$139.50 $139.00 E:` $278.50A
Revised: 08/01/2013