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14040096 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22153 WALLACE DR CONTRACTOR:A&H HEATING PERMIT NO: 14040096 OWNER'S NAME: MENG LIXIN AND WU SHARON X 770 CHESTNUT ST DATE ISSUED:04/16/2014 OWNER'S PHONE: 4085964568 SAN JOSE,CA 95110 PHONE NO:(408)279-0722 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL El COMMERCIAL ❑ ,� REPLACE(E)FURNACE&ASSOCIATED DUCTWORK, License Class C '�2� Lic.It Y�rC_ SAME Contractor 14 wmt!2� Date � LOCATION 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:$9500 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:32602046.00 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 W IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 D F PE IT ISSUANCE E to building construction,and hereby authorize representatives of this city to enter OR upon the above mentioned property for inspection purposes. (We)agree to save 180 DA OM L ED INSPECT O indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the Date: �6 granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations a ino Municipal Code,Section % 9 18. ` RE-ROOFS: Signature l(g^t' 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 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 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent Date: 44 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 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 �O I M E P COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION im 10300 TORRE AVENUE-CUPERTINO,CA 95014-3255 ' CUPERTINO (408)777-3228-FAX(408)777-3333-building(doeugertino.org v MISC X PLUMBING MECHANICAL ELECTRICAL MISCELLANEOUS PROJECT ADDRESS 2 Z 1,5" , I e, O rz- APN# '3 ?-6 02 _ Q t �I OWNER NAME I %r 1� !°- Pm s V J C a� &MAIL STREET ADDRESS 2,Z' W4LL �Y, N ?�k ^ FAX CONTACT NAME � `PHOI�IEU �/) ��22 E-MAIL T A,, `5 �7♦' U FAX ❑OWNER ❑ OWNER-BUH.DER ❑OwmAGENT ®'CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHI wT ❑JTIGINEER ❑ DEVELOPER ❑TENANT COe1 I I LtCI BUS.LIC# COMPANY NAME q+ 1 � h E-MAIL FAX STREET ADDRESS t� � CITY ATI </t /� f PHONE Q A. f6q- C7 ��) j ARCHTIECT/ENGINEERNAME LICENSENUMBER BUS.LIC# COMPANY NAME E-MAIL FAX i STREET ADDRESS CITY,STATE,ZIP PHONE I USE OF ❑sFD o,.DUPLEX ❑ MULTI-FAMILY PROJECT IN wILDLAND ❑ YES PROJECT IN ❑YES LS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN DrIERFACE AREA ❑ NO FLOOD ZONE ❑NO MCHLER HOME? ❑NO DESCRIPTION OF WORK (11 "Lk/ ue- TOTAL VALUATION -00 By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prope owner's behalf.11 this application and the information I have provi ed is L I 1 R+�read the Description of Work and verify it is accurate. I agr mp y with all applicable local ordinances and state laws relating to buil ction. I ut}. size representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Dom: SUPPLEMENTAL INFORMATION REQUIRED .. ° MOW 4 }TII'ITER u MEPMiseApp 2011.doc revised 06121/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION 191 ADDRESS: 22153 WALLACE DR DATE: 04/16/2014 REVIEWED BY: MELISSA APN: 326 02 046 BP#: "VALUATION: $9,500 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY PENTAMATION FURN/AC USE: SFD or Duplex -1 1 PERMIT TYPE: i WORK REPLACE E FURNACE &ASSOCIATED DUCTWORK SAME LOCATION SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Furnace, Forced-Air 1MFR=<100 1 # $139 TOTALS: $139.00 y,,4'G 5 1 (v.^t ..' �. Mech.Plan Check 0.0 hrs $0.00 11111anb. Plan C 1e-cA EYE'<'. P rn Cbs xls Mech.Permit Fee: 1MPERMIT PIamb.Permit Fce: Fther Mech.Insp. 0.0 hrs $47.00 Other Pluirb Irisj;. 0 Uthe`t /stet_In��. r. MN), F""o. P/rtrn7�. Insp. l ea: 1>lec.Ins;). FCC: NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These fees are based on the prelhWdna information available and are onl an estimate. Contact the De t or addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff.' 7/1/13) FEE QTY/FEE MISC ITEMS I'fcur C'Piec"l; Fc't': :uf?cal. P('FCC, PME Plan Check: $0.00 PME Unit Fee: $139.00 PME Permit Fee: $47.00 (_'ons/puction Tcl'v: Administrative Fee: IADMIN $44.00 Work Without Permit? ® Yes E) No $0.00 1clv'cr� <° c PI<t}a iray Fces: Travel Documentation Fee: ITRAVDOC $47.00 i Strong Motion.Fee: IBSEISMICR $0.95 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 -- 5 $278.95 $0.00 _ TOTAL FEE: $278.95 4 Revised: 04/01/2014