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13110087 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10211 VICEROY CT CONTRACTOR:AAA FURNACE&AIR PERMIT NO:13110087 CONDITIONING OWNER'S NAME: BETTENCOURT FILBERT AND JENNIF 1712 STONE AVE DATE ISSUED:11/13/2013 OWNER'S PHONE: 4082494133 SAN JOSE,CA 95125 PHONE NO:(408)293-4717 13. LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL License ClassC Lie.# / UNIT 2-REMOVE AND REPLACE FURNACE Contractor d( Ct.Date C I hereby affirAA- m that I am licensed under the provisions of hapter 9 (commencing with Section 7000)of Division 3 o 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:$3560 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:32615036.00 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 WITfIIN 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 DAY ROM 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 '3 granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: with al t source re ul ions per the Cupertino Municipal Code,Section 9. RE-ROOFS: Signature Date j 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 compliane re pertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safe ode,Sections 5505, 5 and 25534. Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Owner or aut orized agent: ate: 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 ELI] COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION ` 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 Vu (408)777-3228• FAX(408)777-3333•building(c.cupertino.org ` MISC CUPERTINO 1\ 9 PLUMBING HANICAL FlELECTRICAL MISCELLANEOUS PROJECT ADDRESS APN# /5 102AI WWI U04 L4 OWNER NAME �7EMAIL SIpnl� -4133 STREETADDRESSi�2 (I V`fO l:/L ()V1 It2 +j] FAX CONTACT NAME Gc jgwxf PHONA'b .2,-/,;3 .1/3/; o' ,-o E-MAIL STREET ADDRESS CITY,STATE,ZIP / I FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME ^ LICENSE NUMBER!� i LIC BUS.LICA COMPANY NAME A 1+, E-MAIL ` FAX STREET ADDRESS C ZIP v P� -c ,b � n ARCHITECT/ENGINEERNAME ' �j LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WKDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER 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 the pr erty wner's behalf. I have read this application and the information I hav pr vided i orrect. I have read the Description of Work and verify it is accurate. I a 'ee to comply with all applicable local ordinances and state ,=ion to uil Ing c ction. I authorize representatives of Cupertino to enter the abo a-iden ed property for inspection purposes. Signature of Applicant/Agent: Date: M2016 SUPPLEMIENTAL INFORMATION REQUIRED I � MEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS:I 10211 viceroy ct unit 2 DATE: 11/13/2013 REVIEWED BY: Mendez APN: BP#: *VALUATION: 1$3,560 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY PENTAMATION USE: SFD or Duplex PERMIT TYPE: FURN/AC WORK remove and re lace furnace SCOPE rx Mech.Plan Check o.6 hrs $0.00 Plumb.Plarr Chu,( Elec.Ulan Cheep Mech.Permit Fee: IMPERMIT Plumb.Permit l=ee: Elec. Permit Fee: Other Mech.Insp. L2J hrs $47.00 Other Plumb Insp. Chher Elec.Insp. Mech.Insp.Fee: Plumb. hal).Fee: Elec.Insp.Fee: NOTE.This estimate does not include fees due to other Departments(Le Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These eek are based on the; relimina information available and are only an estimate Contact the Dept)*addn'l info. FEE ITEMS(Fee Resolution 11-053 E . 7/1113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 0 # Mechanical Suppl.PC Fee: Reg: ® OT 0;0 hrs $0.00 $139.00 IMFR=1100 Furnace,Forced-Air PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp.Feer Reg. :®OT00 hrs $0.00 PME Unit Fee: $0.00 PME Permit Feer $47.00 Conswitetion Tax. Administrative Fee: 1ADMIN $44.00 Work Without Permit? O Yes iq No $0.00 E) Advanced Planning Fee: $0.00 Select a Non-Residential 0 Travel Documentation Fee: ITRAVDOC $47.00 Building or Structure i Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 4FEES"` $139.50 $139.00 �� {� $278.50 Revised: 10/01/2013 iA . ' o mpiin :2ti8Simplified Presrn• •ive Cerdfcate of CResilenta 'AFF-'IR-ALT- Climate CF 1R-ALT-Climate Zones I acid 3-7 SftAddrers Essforaentetsf Agettcy: DaY ` 'emlit# V1C 2 -2 t3 I Con&ioned ,Duct insulation � +L�r'stiim`Efncaen` ";: � iE;•. jr Thmostat'` . entT I .Fioor.'Atea Padcage_d Unit- k1i OCT. dOY Serves by systeat aided orrcgIacxd Setbar� indoor Cog 2ftISP _ (�not rs�ie?d�Presaxb Awl be .condensing Unit ® 'EER Resuce sf tiacxindtioned space Offer E3 R 6 (CZ J.Equipment Type:Choose the equipment being installed;if more than one_systmn,use another CF-lR-ALT,HVAC.for each system. 2.Minimum Equipment Wciencies:13 SEER,78°/a AFUE,7.7HSPF for typical residential:systems. Contmctor'(Docuraenta 'on Author's/Respousible Designer`s Dmlaration Statement) • i certify that this CertWeatc of Compliance documerrudon is accurate and coin`piete., • I am eligible under Division 3 of the California Business and Professions Code to accept responsibility forthe design identified.on this Certificate of Compliance. • I certify that the energy features and performance`specifications for the design identified on this Certificate of Compliance conform to the requirements of Title 24,Parts I and 6 of the California Code of Regulations. • The design.fcalures identified on this Certificate of Compliance are consistent with the information documented on other applicable compliance forms,wor3 sheets,calculations,plans and specifications.Fu 7i ted toM ant agency for approval,with the permit. application. Nance Onj /1i? Signatwe: Companr. l►U ,nes' D ate Address: �v/� •�1�v1 Va- �.1. .. '. Incense: �� City/Staie/Zip: �1Y� 7 ✓; ;t .. ' PliQiie' �I 1 2008 Residential Compliance Forms.doc revised 04110/12