14120094CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22664 SILVER OAK LN
CONTRACTOR: ATLAS-TRILLO HVAC
PERMIT NO: 14120094
OWNER'S NAME:
SAN JOSE, CA 95125
PHONE NO: (408)286-8931
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL
REMOVE AND REPLACE FURNACE IN SAME LOC.
License Class Li,. #
1�
�..., /
Contractor Date !L/_ _1�
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:
will maintain a certificate of consent to self -insure for Worker's
Vhave
tion, as provided for by Section 3700 of the Labor Code, for the
ce of the work for which this permit is issued.
Sq. Ft Floor Area:
Valuation: $2000
I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 34249013 00
Occupancy Type:
Section 3700 of the Labor Code, for the performance of the work for which this
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
WITfIIN 18PERMIT 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 FOM ST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
t /
costs, and expenses which may accrue against said City in consequence of the
Issued by: Date:
granting of this p mit. Additionally, the applicant understands and will comply
with all non -poi urce regulations per the Cupertino Municipal Code, Section
9 18.
RE -ROOFS:
Signature Date
All roofs shall be inspected prior to any roofing material being installed. If a roof is
for
installed without first obtaining an inspection, I agree to remove all new materials
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 w' a Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety
Date:J� *
—T
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
CITY OF CUPERTINO
10 U c'TTl%4 A r1rn1D — i211TH .n-FNC DIVICION
ADDRESS: 22664 silver oak In
DATE: 12117/2014
REVIEWED BY: Mendez
APN:
BP#:
*VALUATION:
$2,000
PERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
SFD or Duplex
1
PENTAMATION FURN/AC
PERMIT TYPE:
USE:
Per mif P'ee:
S` rt rrl. h l s ') Fe
WORK
remove and replace furnace in same loc.
SCOPE
$143.00
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Furnace, Forced -Air
1MFR=<100
1
#
$143
Per mif P'ee:
S` rt rrl. h l s ') Fe
PME Unit Fee:
$143.00
PME Permit Fee:
$48.00
Administrative Fee: 1ADMIN
$45.00
Work Without Permit? 0 Yes Q No
$0.00
TOTALS:
i
Travel Documentation Fee: 1TRAVDOC
$143.00
Strong Motion Fee: IBSEISMICR
Mech. Plan Check 0.0 1 hrs $0.00 P1,11117h. Plan C.'hc0l,
Mech. Permit Fee: IMPERMIT Piramh Ptrmu Pei::
Other Mech. Insp. 0.0 hrs $48.00 0(her Plurnh Iran.
Wcch. Irrsl;. h 11;zanh. Insp. Fee:
NOTE: This estimate does not include fees due to other uepartments (t.e. manning, ruanc rr urno, i'ttG, Uu/--y��••��-
-_-....n-zt.......1 ,...,. --I- __ octarrnfo /'nnfnrt lha Aanf for nddn'I info.
"Istrict, eta 1 rt G11G GGJ .1. V—. — woc V'-
.wFEE ITEMS (Tee Resolution 11-053 Ef. . 7/1/13)
FEE
FEE
QTY/FEE
MISC ITEMS
I'1c7n C'hccI I -tic':
si'lppl. PC 1"ce
PME Plan Check:
$0.00
Per mif P'ee:
S` rt rrl. h l s ') Fe
PME Unit Fee:
$143.00
PME Permit Fee:
$48.00
Administrative Fee: 1ADMIN
$45.00
Work Without Permit? 0 Yes Q No
$0.00
r
�t�'3'ksrc�r� �'�<rrrrlrn�;r t,�cs:
i
Travel Documentation Fee: 1TRAVDOC
$48.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldp Stds Commission .Fee: IBCBSC
'
$1.00
$285.50
$0.00[kTORI AL FEE c
$285.50
Revised: 10/01/2014