14100135 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22424 MCCLELLAN RD CONTRACTOR:VALLEY HEATING& PERMIT NO:14100135
COOLING
1171 N 4TH ST DATE ISSUED: 10/22/2014
OWNER'S NAME:
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL E]
p�( , REPLACE(E)FURNACE&(E)DUCTWORK(SAME
License Class Li..# LOCATIONS)
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 Valuation:$3247
performance of the work for which this permit is issued. Sq.Ft Floor Area:
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:35604023 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above in
is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITIIIN 180 DAY RMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter LED INSPECTION.
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY L a
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ate:
granting of this permit. Additionally,the applicant understands and will comply
with all non-point?)
_ e regulations per the Cupertino Municipal Code,Section
918. � J �L RE-ROOFS:
Signature '-' Z/ / 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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) HAZARDOUS MATERIALS DISCLOSURE
1,as owner of the property,am exclusively contracting with licensed contractors to
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
the Health&Safety Code,Sections O5,25533,and 25534.
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 Owner or authorized agent: Date:
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
I hereby affirm that there is a construction lending agency for the performance of
become subject to the Worker's Compensation provisions of the Labor Code,I must
work's for which this permit is issued(Sec.3097,Civ C.)
forthwith comply with such provisions or this permit shall be deemed revoked. 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
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
11 M. ADDRESS: 22424 McCLELLAN RD DATE: 10/2212014 REVIEWED BY: MELISSA
PN: 356 04 023 BP#: "VALUATION: $3,247
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
2-
TPENTAMATION FURN/AC
PRIMARYSFD or Duplex TYPE:
USE:
WORK REPLACE E FURNACE & E DUCTWORK SAME LOCATIONS
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $143
TOTALS: $143.00
Mech.Plan Check 0.0 hrs $0.00 1'lrr+t�h. Platt C heck
Mech.Permit Fee: IMPERMIT
Other Mech.Insp. 0.0 hrs $48.00Other Plumb lrt:vp.
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fare,Sanitary Sewer District,School
District,etc. . These ees are based on the relimina in ormation available and are onl an estimate Contact the De t or addn'1 in o.
FEE ITEMS (Fee Resolution 11-053 E . 7ff /1/13) FEE QTY/FEE
MISC ITEMS
PME Plan Check: $0.00
1'L>t'r,art I°'gym:
PME Unit Fee: $143.00
PME Permit Fee: $48.00
Administrative Fee: 1ADMIN $45.00
Work Without Permit? ® Yes (E) No $0.00
Travel Documentation Fee: ITRAVDOC $48.00
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission.Fee: IBCBSC $1.00
a.
�, _� $285.50 $0.00 T f{TAL FEE: $285.50
Revised: 08/20/2014