15010016 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11706 PALM SPRING CT CONTRACTOR:SERVICE CHAMPIONS PERMIT NO: 15010016
OWNER'S NAME:
PLEASANTON,CA 94588 PHONE NO:(925)444-4444
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
FURNACE REPLACEMENT
License Class C Z V Lic.# Q 17 a
Contractor GyUrce, &WPt&A5 Date y "
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
erformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$5828
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:36654112.00 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 D E 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 DAY RO AST 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 b Date: Q [
granting of this permit. Additionally,the applicant understands and will comply y'
with all non-point source regulations per the Cupertino Municipal Code,Section
9 18.
(�
"� Date All roofs shall be inspected prior to any roofing material being installed.If a
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)
1,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
the Health&Safety Code,Sec'ons 25505,25533,and p25534.
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 L-S��5
p Owner or authorized age 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
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
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 11706 palm spring ct DATE: 01/05/2015 REVIEWED BY: Mendez
APN:
ADDRESS:
*VALUATION: $5,828
xPERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY ---7PENTAMATION FURN/AC
USE: SFD or Duplex PERMIT TYPE: i
WORK
SCOPE furnace replacement
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Gravity-Type 1MFR=<100 1 # $143
TOTALS: $143.00
n;
Mech.Plan Check 0.0 hrs $0.00 fPhoilb, P16M C'h&'k C'rei:,LIP'hw7 xli
Mech.Permit Fee: 1MPERMIT x'h"M& /'ermij 1-= �. �'<'.�'�'�z=t'�'�:
Other Mech.Insp. 0.0 hrs $48.00 Oilier Numb Ir1sp. oder Gio' h sf,.
:1l xn.ta,.ct�.i�:e. plurilb. I�rs/�. Fee 1.it-c.Itis"). f-1-'e:
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These fees are based on the prefimina information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 M. 711113) FEE QTY/FEE MISC ITEMS
Ilan C.Chcc 1c Fce:
SvppL
PME Plan Check: $0.00
Permit
rS alop 1. 1;a s p 1'e e
PME Unit Fee: $143.00
PME Permit Fee: $48.00
Con,vruciion lira-:
Administrative Fee: IADMIN $45.00
Work Without Permit? 0 Yes (j) No $0.00
-1(IMIZ(V1 Planning 1"eekv:
Travel Documentation Fee: 1TRAVDOC $48.00
Strom Motion Fee: IBSEISAECR $0.76 0 # Revisions
Bldg Stds Commission Fee: IBCBSC $1.00 $0.00 1REVSFDWL I SFDWL
�B ® $285.76 $0.00 TOTAL FEE:-F7 $285.76
Revised: 10/01/2014