1409012214
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19503 STEVENS CREEK BLVD UNIT 328
CONTRACTOR: RESIDENTIAL HEATING
PERMIT NO: 14090122
AND A/C INC
OWNER'S NAME:
CAMPBELL, CA 95008
PHONE NO: 4083774073
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
REMOVE AND REPLACE HVAC UNIT ON ROOFTOP AND
License Class � Lic. # ~%��
FURNACE IN SAME LOC.
Contractor ACQdOAtIIGI�Date _I
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
Sq. Ft Floor Area:
Valuation: $13170
erformance of the work for which this permit is issued.
ave 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: 31649096 00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT E ORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 AYS OF P + IT 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 DAYS F T C LLED 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
q
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
RE -ROOFS:
9 18.
/
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
Section 3700 of the Labor Code, for the performance of the work for which this
the Health & Safety Code, Sections 25505, 25533, and 25534.
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
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'pe_r the Cupertino Municipal Code, Section
Licensed Professional
9 18.
Signature Date
CITY OF CUPERTINO
FFF. FCTIMATOR — RITII,DING DIVISION
ka,ADDRESS:
19503 scb unit 328
DATE: 09/19/2014
REVIEWED BY: Mendez
APN:
BP#:
"VALUATION: $13,170
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY
USE: SFD or Duplex
Suppl. PC Fee: Reg. 0 OT
PENTAMATION
PERMIT TYPE: FURN/A ;
WORK
remove and replace hvac unit on rooftop and furnace in same loc.
SCOPE
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, r'ire, Sanitary Fewer District, 5cnool
L.......1 .. s/...
FEE ITEMS (Fee Resolution 11-053 E f 7/1/13)
FEE
QTY/FEE
7- MISC ITEMS
Plan Check Fee:
$0.00
= it
$143.00
Mechanical
IMFR=<100 Furnace, Forced -Air
Suppl. PC Fee: Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
1 #
$72.00
Mechanical
1 IBREMAIR A/C Units (<=10K cfm)
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. ® OT
10.0
1 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$48.00
�,£;it,>f7'rt%fliJYi rct.'t.
J_T
Administrative Fee:
]ADMIN
$45.00
G
Work Without Permit? ® Yes (F) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
E)
i
Travel Documentation Fee: ITRAVDOC
$48.00
Strong Motion Fee:
IBSEISMICR
$1.71
Select an Administrative Item
1
Bldp- Stds Commission .Fee: IBCBSC
$1.001
1 1 �L
$143.71
$215.00
[
TOTAL'- TOTAL FEE:
$358.71
Revised: 08/20/2014