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14020063CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22025 CREEKSIDE CT CONTRACTOR: ONE HOUR HEATING PERMIT NO: 14020063 AND AIR OWNER'S NAME: ABHAY BHORKAN & MANSI MODAK 1400 PETALUMA HILL RD DATE ISSUED: 02/11/2014 OWNER'S PHONE: 4082422169 SANTA ROSA, CA 95404 PHONE NO: (707) 545-1800 Er LICENSED CONTRACTOR'S DECLARATION License C1assC O 2 -6 0 Lic. # -(0 ( ` Contractor Date ' I hereby of tha 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. 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 permit is issued. APPLICANT CERTIFICATION 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the 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. Date 2 - r/ � / I ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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 construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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. 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 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 become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the 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. Signature. Date JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL E] REMOVE AND REPLACE FURNACE IN SAME LOCATION Sq. Ft Floor Area: I Valuation: $7720 APN Number: 32639039 00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN PERMIT ISSUANCE OR 180 DAYS O ST CALLED INSPECTION. Issued by: Date // RE -ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 505, 25533, and 25534. z-ir-rf Owner or authorized agent: Date: CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C ) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CUPS TINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 103 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 •'FAX (408) 777-3333 • buildina(8cuoertino.org rl x .rcnv A wrrr A 7 M IZ7 PrTR Tr A T 141'tt — MISCELLANEOUS MEP MISC U ri,viviniixu PROJECT ADDRESS 2 2 O 2 C ��y�� (/S' ��J c4 • I APN # 7 �'YC�!`'r— E-MAIL P • 2421 •2 14 1 1 OWNER NAME Abhn STREET ADDRESS�eC7 _L ` Cn' �! 44TN O C� 17 O t I FAX CONTACT NAME PHONE Fhb STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER '❑ OwTTER-BUILDER ❑ OWR.ERAGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT /-� `r CONTRACTOR NAME JZLOr _ 0 our T'( LICENSE ER LIC�EN� L� BUS. LIC # MNAME COPAA'Y NA E-MAIL E-MAIL FAX STRE ADDRESS �o a�vrna h' c� t'd CITY, STATE ZIP G aSa g5�� PHONE ?o S • l80d ARCHITECT/ENGINEER NAME LICENSE NUMEER BUS. LIC # COMPANY NAMEE-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX ❑ MULTI-FAMQ.Y PROJECT INWIL.DLAND ❑ YES BUIIDINCr ❑ COMMERCIAL URBAN INTERFACE AREA ❑ NO PROJECT IN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICIMM HOME? ❑ NO DESCRIPTION OF WORK IQ ca %\ ,r. h a C TOTAL VALUATION: Z� i NO ,ma x - M By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the prop rty owner's beha ve read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I mply v ith all applicable local ordinances and state laws relating to buildm n. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: 2 - c`/ • l7 SUPrLEMENTAL INFORMATION REQUIRED :OV �S'1�CO�.,�TER' �_ >>J = - N s'. ST,A�D�1RD �. MEPMiscApp_2011.doc revised 06/21/11 FORFO �� CITY OF CUPERTINO — li/I�i FF.F. F.CTTMd►TnR — RITILDING DIVISION im,ADDRESS: 22025 creekside ct DATE: 02/11/2014 REVIEWED BY: MENDEZ APN: BP#: "VALUATION: 1$7,720 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: p hrs PENTAMATION FURN/AC PERMIT TYPE: WORK remove and replace furnace SCOPE NOTE: This estimate does not include fees due to other Departments (i.e. Hanning, runic worKs, rire, ,3amrarynewer "iszrici, acauui ,. _ L,. ...i ,... sL('nntart the Dent for addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/132 FEE wb ,!�r MISC ITEMS Plan Check Fee: $0.00 0 # $139.00 Mech. Plan Check 0.0 hrs $0.00 Phunb> Plan (Ju"d $0.00 PME Plan Check: E/ec. P/un C;h>:ck Mech. Permit Fee: IMPERMIT $0.00 Ptzrmla Permi9 Fee: 0,0 hrs f' <e: Mech. Insp. 0.0 hrs $47.00 Otlwr Plumb Insp,F-1 PME Permit Fee: I CJrlr<rf' F,iec. 1n,/z Lj Lther phan/2 Ins!). Fee: 1ADMIN I l(:C. Iny, f "C' NOTE: This estimate does not include fees due to other Departments (i.e. Hanning, runic worKs, rire, ,3amrarynewer "iszrici, acauui ,. _ L,. ...i ,... sL('nntart the Dent for addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/132 FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 0 # $139.00 Mechanical IMFR=<loo Furnace, Forced -Air Suppl. PC Fee: (j) Reg. ® OT 0.0 1 hrs $0.00 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 1 0 G Work Without Permit? ® Yes (E) No $0.00 Advanced Planning- Fee. $0.00 Select a Non -Residential Building or Structure O 0 A Travel Documentation Fee: 1TRAVDOC $47.001 Strong Motion Fee: IBSEISMICR $0.77 Select an Administrative Item BldaStds Commission Fee: 1BCBSC $1.00 N �° N. $139.77 $139.00. TOTAL FEE; $278.77 Revised: 01/15/2014