13120198 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21561 REGNART RD CONTRACTOR:LISA GEIFER-LEE PERMIT NO:13120198
OWNER'S NAME:
JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL ❑
REMOVE AND REPLACE FURNACE IN SAME LOCATION
License Class Lic.#
Contractor Date
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:$2500
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:35622006.00 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 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 ROM LAS 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 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
918.
RE-ROOFS:
Signature Date 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,
wp do the work,and the structure is not intended or offered for sale(Sec.7044,
..siness&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 M74-agement District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino ipal ,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Cod�ecti 55 , 553 d
S tion 3700 of the Labor Code,for the performance of the work for which this Owner or authorize
Compensation laws of California. It 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 ap t understands and will comply
w'
Date
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 21561 regnart rd DATE: 12/23/2013 7 REVIEWED BY: mendez
APN: BP#: *VALUATION: 1$2,500
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex. PENTAMATION FURN/AC
USE: R PERMIT TYPE:
WORK remove and re lace furnace in.same location
SCOPE
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'+4
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Mech.Plan Check 0.0 hrs $0.00 Plrsrrrb.Plzen Check Flee.Plan C"heck
Mech.Permit Fee: 1MPERMIT Plumb.Permit Fee: lilec. Permit fee:
Other Mech.Insp. 0.0 hrs $47.00 Other Plumb Insp Other Elec.Insp. Li
He& Insp,Fee: Plumb. lnslr.Fee: I Elec.Insp, Fee:
NOTE:This estimate does not includefees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These fees are based on.the prelimina information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Ef. 7/1/131 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 F 1 1 # Mechanical
Suppl.PC Fee: (F) Reg. Q OT FO.OThrs $0.00 $139.00 1MFR=<100 Furnace,Forced-Air
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Feeig Reg. ®'OT 0;0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $47.00
Construction T xr:
Administrative Fee: IADMIN $44.00 0
Work Without Permit? ®Yes (E) No $0.00 E)
Advanced Planning Fee: $0.00 Select a Non-Residential
Travel Documentation Fee: 1TAVDOC $47.00 Building or Structure
R
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Feer IBCBSC $1.00
rs.�.�
� �ti,
$139.50 $139.00 10 ° F $278.50
Revised: 10/01/2013