14050005 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22036 ACACIA WAY CONTRACTOR:ONE HOUR PERMIT NO: 14050005
HEATING AND AIR
OWNER'S NAME: 1400 PETALUMA HILL RD DATE ISSUED:05/01/2014
OWNER'S PHONE: SANTA ROSA,CA 95404 PHONE NO:(707)545-1800
❑ LICENSED CONTRACTOR'S DECLARATION � ]"
/t/� 9 �j�+ BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Classt.-t U CI C) Lic.# 74Q ( Z 47 J-" F ("
?'� r MECH RESIDENTIAL COMMERCIAL
Contractor '"7�— Date J ` 16( JOB DESCRIPTION INSTALLATION OF NEW A/C SYSTEM(COMPRESSOR TO
I hereby a at I am Ised under the provisions of Chapter 9 FT FROM THE PROPERTY LINE).
(comm ng 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:$4513
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:32602075.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, oo
costs,and expenses which may accrue against said City in consequence of the ,,l G
granting of this permit. Additionally,the applicant understands and will comply Issued by: ,v �"II�� Date: 7
with all non- per the Cupertino Municipal Code,Section
9 18.
U RE-ROOFS:
Signat Date r 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
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
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. 1 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,
Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Owner or authorized agent. Date:
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. 1 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, ARCHITECT'S DECLARATION
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 E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408) 777-3228•FAX(408)777-3333•building aecuaertino.orq MISC
6Mro
❑PLUMBING p/J MECHANICAL ❑ELECTRICAL ❑MSCELLANEOUS J
PROJECT ADDRESS 22,036 o G t-f fr I A PN# 3V a I 1,P 0
0 n-7
s
E-MAIL OWNERNAME n % I • /OO
STREET ADDtS2 0,3 / . cot evq A 1,5-6 '4 FAX
PHONE � a a
—1 'avj, )-eaf r H 9 0 Sf5• f goa
12 it DRP,�.4S ` tovVi Ol r�t c rci I>1/A' Q�r `o,,; - , c-4 q Y0 I I FAX
❑ OwNER ❑0 OWNER-BUI DER ❑ OIANTER AGENT .2 CONTRACTOR ❑CONIRACTOR AGENT ❑ ARCHIrEcT ❑ENGINEER ❑ DEVELOPER ❑TENANT
COIVTRACTORNAME I LICENSE T�jiel 0 Gn� I LIC�ENS�O C BUS.LIC# 337-
COMPANY NAME E-MAIL. FAX
(7 11 FAX
STREET ADDRESS CITY,STATE ZIP PHONE
^-7
ARCHTTECT/ENGINEERNAME i LICENSE NUMBER BUS.L'ICs#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF FD or DUPLEX ❑ NM71-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING COMMERCIAL I URBAN ITERFACE AREA NO I FLOOD ZONE I'NO EICHLER HOIvM? ANO
DESCRIPTION OF WORK A a4 r Oh
TOTAL VALUATION: _RFC ���
By my signature below,I certify to each of the following: I am the property ovmer or authorized agent to act on the property o�mer's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply v>ith all applicable local
ordinances and state laws relating to�bu* i c ' n. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: �• ( T
�PPLEMEI\TTAL INFORMATION REQUIRED
- gm
a�
.•�-'.`� - ---
TANDAI2D�
AM
MEPMisc.4pp_M1.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
12 ADDRESS: 22036 Acacia Way DATE: 05/01/2014 REVIEWED BY: Sean
APN: I BP#: ������ ''VALUATION: $4,513
*PERMIT TYPE: Mechanical Permit I PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: p I PERMIT TYPE:
WORK I installation of new A/C system (compressor to be 3 ft from property line).
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
A/C Units (<=10K cfm) J 1BREMAIR 1 # $70
TOTALS: I I $70.00
_
Mech.Plan Check 0.0 1 hrs $0.00 P1,11n h, /'Nara Cix,,-A I I 1.,""< . iVr v? -('P I I
Mech.Permit Fee: 1APERMIT
Other Mech.Insp. 0.0 hrs I $47.00 taro 1'114n7b lnr-p.
Inuo. VAS: Phtmh. hasp.Fee:
NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). These lees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 711113) FEE QTY/FEE I MISC ITEMS
1' tti c...r.c't'+
Slq)jd PC
PME Plan Check: $0.00
PME Unit Fee: $70.00
PME Permit Fee: $47.00
Administrative Fee: IADMIN $44.00
Work Without Permit? ® Yes 0 No $0.00
�C,{;'Citt,:'t'tl!°isr7?i71i'74r Fees:
Travel Documentation Fee: ITRAVDOC $47.00
Strom Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldv Stds Commission Fee: 1BCBSC I $1.00
,,._<< OTALS•:' 209.50 $0.00
$ TOTAL FEE: I $209.50
Revised: 04/01/2014