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13110027CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21572 COLUMBUS AVE CONTRACTOR: SERVICE CHAMPIONS PERMIT NO: 13110027 OWNER'S NAME: BRUCE FUJIKAWA 7020 COMMERCE DR DATE ISSUED: 11/05/2013 OWNER'S PHONE: 4082526448 PLEASANTON, CA 94588 PHONE NO: (925) 444-4444 N LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL LJ V REPLACE 12 SUPPLY DUCTS AND 1 RETURN License Class Li.. # (� tlllfi�� Date ContractoriU'-(.2J 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: $7701 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: 35618056.00 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 180 DAYS OM LAST CALLED INSPECTION. upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, City in consequence of the �} costs, and expenses which may accrue against said Issued by: Date: granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. l r / + � RE -ROOFS: being installed. If a roof is Date � All roofs shall be inspected prior to any roofing material Signature Signature � 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, do the work, and the structure is not intended or offered for sale (Sec.7044, will Business & Professions Code) property, rty, am exclusive) contracting with licensed contractors to 1, as owner of the roe y g 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 Code, Section 25532(a) should I store or handle hazardous declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's Health & Safety 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 compliance with the Cupertino Municipal Code, Chapter 9.12 and performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by will maintain the Health & Safety Code, Sc ti ns 25505, 25533. and 25534. I Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent. ( 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 CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after making this certificate of exemption, I I I hereby affirm that there is a construction lending agency for the performance of become subject to the Worker's Compensation provisions of the Labor Code, must work's for which this permit is issued (Sec. 3097, Civ C.)Lender's forthwith comply with such provisions or this permit shall be deemed revoked. 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 PERI' APPLICATION MEP im 10300 TORE AVENUE - GU=t__r_tt N0, CA 9r0 -3255 ou (408) 7T7-3228 - FAX (AM) —777-3333 - 1 �O misc CUPERTINO r�t . `7�� I I ,}�pr-rpirAT 1 I\VMCEtTArr US _&fEp,j&,,�,v3oj1.doc revised 06n1fi1 c, W) ba S pr l � Seo 35 (v e OOWNMNAP-a llULi �U. ir.. U,�qT�, srs�-raun�s,.5�1 1.9.t'V1 h li S r�'t %-�- sra FAX t�NTALT Nam PHONE 5I3.ETADORM MY. STATE_ r. p FAX a oWWM ❑ GWNEIL� a 0 M-4ZENT [3E3A3Chi = o Q -� a r�tnr, ( N.� ; r I o-1 L 7 Em Lic ( If FAX COWANYM&Or i (( c l�V� Vli� Il✓ i,'� �= SMIL s�rAM� ttiJ c`�'� q /z/ L` M MZ tnf� NTSoEFL am uci'— _yr. rax cOn�.wY ruac ' srxMEZu70B3'S czY. STAT; Z__ a�crc uMOF Sr[7armr z ❑ u= 2A�d_Y ?SIIi�i?i: Ti �F 1�iI ❑ 7E- P 1�A t 0 *uo ` Y3 L4 : 3Z +.GAN Q `� EDOD�E C`tO ;gR aTnu II- rT Os VI= ( L�( lZ -� lAr1� ! � C lA ►�� zacsvm Err:�roTAr:v.L*,errs»- -�'i C� i • t� By MY sj�c heia4P I —,in? to �h �3rc {adlaw:a� I �t tht ocvicer ra 'rt ID act ca site paparf s beisalt I hart rcmd tza s='_ of Two& z~ 5j u is a=m -am I a� a cif wilt aL =Habklocal nxve read tine = �piic�� aad tIx I tsave navvided is c ad i� ms af50 3Fnva-tom F t � P Sj_Wtahe afAgpficaattA SUPPi�TAL LNFORMATION REQ F OFFICE t&E ONLY �ET.Ii�{Otu`t'FR ffi Q FJ�R x U 5 0 M41WAW U ^� _6 Lu= I( !S C MR3QR _&fEp,j&,,�,v3oj1.doc revised 06n1fi1 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 21572 columbus ave DATE: 11/05/2013 REVIEWED BY: Mendez APN: BP#: `VALUATION: $7,701 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY PENTAMATION 1 RMAP7 USE: SFD or Duplex PERMIT TYPE: wORK re lace 12 supply ducts and 1 return SCOPE APPLIANCE / EQUIP TYPEE ID 1111 1b 1'-`«,� < l,,°t� QTY UNITS BP FEES ;i', r . Por„rr Ventilation System FlB�REMVMVENS 1 # $104 Permit 1 e: suppl. Insp Fee PME Unit Fee: $104.00 PME Permit Fee: $47.00 C;'onstl action Tax: Administrative Fee: ]ADMIN $44.00 Work Without Permit? ® Yes (F) No $0.00 �1ell'aiwell Plamliny, TOTALS: $47.00 Strong Motion Fee: ]BSEISMICR $0.77 $104.00 Bldg Stds Commission Fee: IBCBSC NOTE: This estimate Goes not tnetuaejees aue w vunei 1.-. �-»•-•----a, - ------ - � ^ ^^F ��^ nn^` � r ��n'1 info District etc . These fees are based on the rettmtna FEE ITEMS (Fee Resolution 11-053 E . 7/1113) Plan .Chc k Fee: Mech. Plan Check 0.0 hrs $0.00 1111 1b 1'-`«,� < l,,°t� t; ��. l ioln C{ark Mech. Permit Fee: IMPERMIT F,�' n ;i', r . Por„rr Oth11c,er Mech. Insp. 0.0 hrs $47.00 ])rbc; 1 /,��;�1� I,,tf� - Ph;uih. h,s/z /-erg: n..ILI.'- W-1— t:iic'. h7q), Pcc- =— C—it—r.Vo or Di.ctricL Schoo[ NOTE: This estimate Goes not tnetuaejees aue w vunei 1.-. �-»•-•----a, - ------ - � ^ ^^F ��^ nn^` � r ��n'1 info District etc . These fees are based on the rettmtna FEE ITEMS (Fee Resolution 11-053 E . 7/1113) Plan .Chc k Fee: to orinuuva uvuuu..c FEE �......• QTY/FEE �.•. »•• ��--••_ MISC ITEMS Suppl. PC Fee PME Plan Check: $0.00 Permit 1 e: suppl. Insp Fee PME Unit Fee: $104.00 PME Permit Fee: $47.00 C;'onstl action Tax: Administrative Fee: ]ADMIN $44.00 Work Without Permit? ® Yes (F) No $0.00 �1ell'aiwell Plamliny, Travel Documentation Fee: ITRAVDOC $47.00 Strong Motion Fee: ]BSEISMICR $0.77 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $243.771 $0.00 TOTAL FEE: $243.77 - J. A^1^.1/7/I.IR 1\GYIJG�J• �v.v ..ry ... cNM2ft Zama I I* IS Del- 57tt.# r- � C) 1.1 VO rJl r/\. US EV I- II €w cess er cop— E3106= CI E3 1sk L' R L Xz ISL} _ -I c s 1 Z �,�• �Hr 21 SO i s- s. FWAM Dud - ;;a�4 1st Dad kakage<15 LL _a• s ""W20"3 qpam r�,��, - -ad Farm= 13? Maw Reqah �.��y 3g _}s '-� CF4R For 1�� s ��accE .t"r—a 4! Amt gm 40 IR jM:hxjCv*dt=g w — �¢ cia=� ' JpEt 1w �e aw-a - -�, T2s <15 Md s -F -«4, B sS �i is r-7 OZ M S FM —� FM9Amfi&,� cMwu== F-br=