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13100114 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10431 WESTACRES DR CONTRACTOR:SERVICE CHAMPIONS PERMIT NO: 13100114 OWNER'S NAME: TSING JOHN Y AND MICHELLE L 7020 COMMERCE DR DATE ISSUED:10/16/2013 OWNER'S PHONE: 4089731925 PLEASANTON,CA 94588 PHONE NO:(925)444-4444 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL License Class QQ 610 Lid.# q1 70W REPLACE(E)FURNACE,SAME LOCATION Contractor aW'Uia, r �C.Date�P' J 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:$4024 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:35914029.00 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 180DAYS F ALLED 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 Z Z1,6 �3 granting of this permit.Additionally,the applicant understands and will comply Y Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature u Date lU lD / 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 1,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 25505,25533,and 5534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:W Zco J 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 ofthis 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 GSL PERMIT APPLICATION 1 MEP CO�r�r DEFT--RUUDIMS 0� -1 W W TC f U ZTEAV-Ra M-�,CA9M-M `0 cuFF�xo (4W)=�-f AX( ��- -= 1i mist pF,L *G i1MMA22Fit'_aT QtZF.GMCAL [IMSMLaTaOUS OWNEMAbM So h V, �Lipj2jt no f.OAirACr NAS `MA3L sra rannmss �:..EFrnx Q owma LI awmmaumm II owietmaNr iYcw=Ac= E3cmwmAczatAaEwr Q Aacmncr Q t O + eom^a Cl t-tAvr fWeAWYWAlO f Uic--moi - FAX 03afEiy'UM9EL aB4.L*C coaaraivsrrraa - =-MAIL MAX ST3�TA CCLY.m-�, PSOWE um OF 1�VZMEAM Lt YF.-: El Iss zs��cAN Q ym ElCMOMMMALs g NO FEDCD G rw SCHE 3mdW Um nOF� - tCt.c,.� TOTALVALUAXORt "f - By- sa E ttssas�cc�t7nc Zaaztite gaaser�ar� tzr�ix�tSfl i�vc T fi��dzcIh�c3is^a—�,��z��eElar"v'�o�c��F�g � �hzL�taEcah3e�al Lam �P �rnetroa; riesaEC��e:,.rr� -- apes�cs[ �p .samdst�lawsT IO_i( I3�3� I lC D a u - 9 0 Lk-= Aj PW,-c,j"jVlLdoc revised 061?I/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION all ADDRESS: 10431 WESTACRES DR DATE: 10/16/2013 REVIEWED BY: MELISSA APN: 359 14 029 BP#: *VALUATION: 1$4,024 *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 SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Furnace, Forced-Air 1MFR=<100 1 # $139 sem= TOTALS: $139 00 Mech.Plan Check 0.0- hrs $0.00 Phinih.Plan Check Elec.Plan Check 1Vlech.Permit Fee: 1MPERMIT Plumb.Permit Fee: Elec. t'ermiY Fee: FOt,hET r Mech.Insp. 0.0 hrs $47.00 Other Plumb Insp, [IF Other Elec.Insp. Insp.Fee: Plumb. hasp.Fee: glee,Insp. Fee: NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). Theseees are based on the relimina information available and are onlyan estimate. Contact the Dept or addn'1 info. FEE ITEMS(Fee Resolution 11-053 E . 7f /f 1j13) FEE QTY/FEE MISC ITEMS Plan Check Fee: Stipp 1..PC F'ee PME Plan Check: $0.00 Perinit Fee: Supp/, Insp fee PME Unit Fee: $139.00 PME Permit Fee: $47.00 Consiniction 7'ax: Administrative Fee: IADMIN $44.00 Work Without Permit? ®Yes JaNo $0.00 Advanced Planning Fees: Travel Documentation Fee: ITRAVDOC $47.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg,Stds Commission Fee: 1BCBSC $1.00 $278.50 $0.00 TO LFEE. $278.50 Revised: 10/01/2013 Pam:me ikt* l( 3t t1�es�aes 7/� D IIS-13 I mss' U etIC ii UlCW isir M led=coff R xxIJ�13jx 7 a _mm '=dfi= s e 3 a m s---s` ��r �4tRwd -- fiN--sikal r ? s 3n-R-`?sr- 21 aei ; X 25 --------------- s Cod amd Icr t 2W ad iff-W10cm-25 Fes. _�c ii. _ pw� Umas: Dud 4 Fvrc5rs-3_spm Dadicakw � , For PteklPd 0ab=DGe 43- �F CH -HERS .:.:.-mean For Dara iia cr CCA?3W€FM-iu:lc.I For Pwblicd Umftw Dua kAW<{EMME D 4_New *VMS:lor— Fermi D «PCZMM '�y fat gas �C14AMPIDM 10 �1 metc—el t j1 Form