15030109Sk
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21083 PATRIOT WAY
CONTRACTOR: VALLEY HEATING &
PERMIT NO: 15030109
COOLING
OWNER'S NAME:
SAN JOSE, CA 95112
PHONE NO: (408)294-6290
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ❑
`) Q
L" �; Sy ��
REPLACE (E) FURNACE & A/C, SAME LOCATIONS (NO
License Class Lic. #
DUCT
Contractor Date 3
WORK)
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: $7674
performance of the work for which this permit is issued.
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: 32653053 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 PERMIT ISSUANCE OR
to enter
to building construction, and hereby authorize representatives of this ci�to
upon the above mentioned property for inspection purposes. (We) agresave
AYS INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgm
costs, and expenses which may accrue against said City in consequence
sued Date: 3
granting of this permit. Additionally, the applicant understands an ill comply
Y.
with all non - Cupertino Municipal Code, Section
918.
5111,2115—
RE-ROOFS:
Signature Date
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)
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
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 05, 25533, and 25534.
Owner or authorized agent: Dater
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
F&A-M7 VV 1V 1V Q9P 1%4 A rnI2 _ RI TII .iIINf DIVISION
QADDRESS:
21083 PATRIOT WAY
DATE: 03/17/2015
REVIEWED BY: MELISSA
UNITS
APN: 326 53 053
BP#:
*VALUATION: $7,674
*PERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
SFD or Duplex
#
PENTAMATION FURN/AC
PERMIT TYPE: i
USE:
Furnace, Forced -Air
1MFR=<100
WORK
REPLACE E FURNACE & A/C SAME LOCATIONS NO DUCT WORK
#
$143
SCOPE
PME Unit Fee:
APPLIANCE / EQUIP TYPE
FEE ID
-- -
QTY/FEE
QTY
UNITS
BP FEES
A/C Units (<=10K cfm)
IBREMAIR
1
#
$72
Furnace, Forced -Air
1MFR=<100
Sulypt" Insp Fees
1
#
$143
PME Unit Fee:
$215.00
PME Permit Fee:
$48.00
Consir ttetion Tax:
F71
TOTALS:
Administrative Fee: 1ADMZN
-
$215 00
i,
Mech. Plan Check 10.0 1 hrs $0.00 J.Phanb, Plan Check
Mech. Permit Fee: IMPERMIT I'lumb. Permit Fee:
Other Mech. Insp. 1 0.0 1 hrs 1 $48.001 Other Plumb Insp.
11ft:ch. InspFee: PhirnbG Insp. Fee:
Elec. Plan Check
t-le:c. Permit F -e:
Other Elec, Insp,
Elec. Insp, Fee:
NOTE: This estimate does not includefees due to other uepartments (Le. rcanning, run[Lc rrornJ, .f'[rc, . "19 y �.
Cnntact the Dent for addn'l info.
/1LJ[rLC[, cLc,. 1[[euc ccu wic uawcw vs.,... ,.....•.--•-».
FEE ITEMS (Fee Resolution 11-053 LT 7if /1/13)
..- .-... _-_".-__ ". _--------
FEE
-- -
QTY/FEE
MISC ITEMS
Plan Check Fee:
Szrppl. PC'Fee
PME Plan Check:
$0.00
Permit Fee:
Sulypt" Insp Fees
PME Unit Fee:
$215.00
PME Permit Fee:
$48.00
Consir ttetion Tax:
F71
Administrative Fee: 1ADMZN
$45.00
Work Without Permit? 0 Yes Q No
$0.00
A,1vfdnc ed Plarming 1''ees:
i
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
$1.00
Select an Administrative Item
jr-
6-M
Bldg Stds Commission Fee: IBCBSC
$1.00
" _
$358.00
-
$0.00iE $358.00
Revised: 02/14/2015