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14020058 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10691 HALE PL CONTRACTOR:ENERG SHIELD PERMIT NO: 14020058 OWNER'S NAME: SEREMETA ELENA AND DORIN TRUSTEE 370 PIERCY RD APT B DATE ISSUED:02/10/2014 OWNER'S PHONE: 4089739837 SAN JOSE,CA 95138 PHONE NO:(408)225-5544 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL REPLACE(E)FURNACES&DUCTWORK,SAME License Classes q Lic.# 1 fZ3124—1 7 LOCATION. Contractor t-,�ate 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:$4500 I have and will maintain Worker's Compensation Insurance,as provided for by JSection 3700 of the Labor Code,for the performance of the work for which this APN Number:32640009 10691 Occupancy Type: permit is issued. APPLICANT CERTIFICATION 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 WITIHN 180 MIT 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 ED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,juents, costs,and expenses which may accrue against said City in consequence�ofhe granting of this permit. Additionally,the derstands and wilp y Issued Date: with all non-poi urce regulations p he Cupertino unicipal Code,Section 9 18. t RE-ROOFS: Signature Date L(� 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 qual' agement District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Mu gpaI Code, hapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sec' s 25505,255)d,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Owner or authorized agen . Date: is 6�{ 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 / , . V 10300 TORRE AVENUE•CUP TING, CA 95014-3255 1 (408) 777-3228•FAX(40 77-3333•buildinaacupertino.org i (� cu�lr��ro MISC ❑PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS 7�• L[ _ /Q �� APN# OWNERkNM EMAIL 73 3 . ni t ae_ STREET ADDRESS j / �y I A . � CITY STATE,ZIP. FAX �d. CONTACT NAME � tl PH t o co 6 t E MAII STREET ADDRESS �k • � CITY,STATE ZIP" G, FAX lv'c` ❑ OWNER ❑ OR'NER-BUII.DER ❑ OFRdERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME t p� LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME`-,Ir n �tU� �V"- , E-MAIL FAX STREET ADDRESS G7 �� m f2 CITY,STA1 V�� ARCHTTECT/ENGINEER NAME l� rCF Va LICENSE NUMBER. BUS.LIC# 1�If COMPANYNAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑sFD or DUPLEX ❑ MULTI-FAMII.Y PROJECT IN WI DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO `FLOOD ZONE ❑NO EICHI ER HOME? ❑ NO DESCRIPTION OF WORK BT3TED'B?�� TOTAL VALUATION: 4 By my signature below,Il certify to each of the following: I am erty owner or authorize gent to act on the property owners ehalf. I have read this application and the information I have provided is correct. I Ddve read t Description of Work and verify it is accurate. I agree to comply with all applicable IOcAl ordinances and state laws rel • ilding cons tives of Cupertino to enter the ab e-id ntified ropeertfy,for inspection purposes. Signature ofApplicant/Ag nt: Date: �� T SUPPLEMENTAL INFORMATION REQUIRED Q � OFFSCE�JSE�I�'T�� - as e u1 Rs MEPMisa4pp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10691 HALE PL DATE: 02/10/2014 REVIEWED BY: MELISSA APN: 326 40 009 BP#: `VALUATION: 1$4,500 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex PENTAMATION FURN/AC USE: p PERMIT TYPE: WORK REPLACE E FURNACES & DUCTWORK SAME LOCATION. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Furnace, Forced-Air 1MFR=<100 1 # $139 TOTALS: 1 $139.00 Mech.Plan Check0.0 hrs $0.00 1'l7wlbr Pleat(.'hcc,A h.cof Mech.Permit Fee: 1MPERMIT Plarmb. Pcrmil F"e: laec Pr:r;,;ii Other Mech.Insp. 0.0 hrs 1 $47.00 obrei'Plarmb 7rssp. {)tlrt�f l�;"a`ee tns r. Plaut h Insp, Fee: f`iec.tush t<<e� NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . Theseees are based on the relimina in ormation available and are onl an estimate. Contact the Det or addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/131 FEE QTY/FEE MISC ITEMS Plan Chcck' PME Plan Check: $0.00 r'G'Y1J11t��'. PME Unit Fee: $139.00 PME Permit Fee: $47.00 Administrative Fee: 1ADM1N $44.00 Work Without Permit? ® Yes 0 No $0.00 J vonced Travel Documentation Fee: ITRAVDOC $47.00 A Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldy Stds Commission Fee: IBCBSC $1.00 1 $2 $278.501 $0.00 TOTAL FEE:` $278.50 Revised: 01/15/2014