15030115 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10326 SCENIC BLVD CONTRACTOE PERMIT NO: 15030115
DATER MiNF D
OWNER'S NAME:
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL
REMOVE AND REPLACE FURNACE IN SAME LOC
License Class G Lic.# *NO DUCT WORK*
Contractor _;� ' / Date ,f—��
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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$3000
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:35708035.00 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 DA PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned propertySor inspection purposes. (We)agree to save 180 DAYS F ST CALLED INSPECTION.
indemnify and keep harmless the ty of Cupertino against liabilities,judgments,
costs,and expenses which ma ccrue against said City in consequence of the I F.
granting of this permit. Ad tonally,the applicant understands and will comply Issued by: Date:
with all non-point sourc tions per the Cupertino Municipal Code,Section
9 18.
RE-ROOFS:
Signatur Date 3 —/" ��S 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 M ipaI Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)s 1 store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equ' ent or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Ba ea Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the C no Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Section 5 33,and 25534. J'
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized 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
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 per the Cupertino Municipal Code,Section Licensed Professional
918.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10326 scenic DATE: 03/17/2015 REVIEWED BY: Mendez
APN: BP#: "VALUATION: 1$3,000
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: PERMIT TYPE:
WORK remove and replace furnace
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $143
TOTALS: mF� € $143 00
OR
a ,
MR, . s
Mech.Plan Check 0.0 hrs $0.00 Plumb.Plan Check Elec.Plan Check
Mech.Permit Fee: IMPERMIT Plumb,Permit Fee: Elec.Perrnit Fee:
Other Mech.Insp. 0.0 hrs $48.00 C1(heh•Plumb Inst. t)ther Elec.Insp.
Mech.Insp. Fe-, I Plumb. ]hasp. Fee: Elec.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(i.a Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). Theseees are based on therelimina information available and are only an estimate Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 711113) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Sltppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Suppl, Insp Fee.
PME Unit Fee: $143.00
PME Permit Fee: $48.00
Construction Tax:
Administrative Fee: ]ADMIN $45.00
Work Without Permit? ®Yes (E) No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRA VDOC $48.00 A
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
x,
rNNW
$285.50 $0.00 Tc� .a . $285.50
01
Revised: 02/14/2015