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15050078 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10631 STOKES AVE CONTRACTOR:VALLEY HEATING& PERMIT NO: 15050078 COOLING OWNER'S NAME: BERGSTROM BARRY W AND MARIE B 1171 N 4TH ST DATE ISSUED:05/13/2015 OWNER'S PHONE: 7753093815 SAN JOSE,CA 95112 PHONE NO:(408)294-6290 100 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL 0 �� REPLACE(E)FURNACE IN INTERIOR CLOSET&ADD(N) License Class rLic.# 40AVg'r 7D r A/C UNIT IN REAR YARD Contractor 11 �P./ /7' �+� l r�Da e� /J 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 formance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$13227 ave and will maintain Worker's Compensation Insurance,as provided for by ec' 3700 of the Labor Code,for the performance of the work for which this APN Number:32649015 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 DAYS OF PERMIT 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 0 DAYS ST CALL + INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments costs,and expenses which may accrue against said City in consequence of t Date: J/ granting of this permit. Additionally,the applicant understands and will y' with all non-point ource regulations per the Cupertino Municipal Code,Section 918. -ROOFS: Signature Date rP > All roofs shall be in spe d to any roofing material being installed.If a roof is pop 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 1,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 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 the Health&Safety Code,Secti s)25505,2555534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: r Date:Irl 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 1 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 '1 GENERAL PERMIT APPLICATION du MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION h� 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 � V MISC (408) 777-3228• FAX(408)777-3333•building CUPERTINO (a�cupertino.org i ❑PLUMBING ❑MECHANICAV,p-L ❑ELECTRICAL []MISCELLANEOUS + PROJECT ADDRESS I C k"(7-5 `n•5 A APN# (� ' 01 GI C� E-MAIL ��� ^ CITY, STATE,ZIP I/ (y�/ FAX STREET ADDRESS CONTACT NAME / PHONE �I ? l(�C( lj�� E-MAIL STREET ADDRESS CITY,STATE,ZIP C_ s� C��I��/ FF [3AX OWNER ❑ OWNER-BUII,D/ERI ❑ OWNER AGENT CO/NTRACTOR 11 CONTRACTOR ❑ ARCHIMC[T ('❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME 1 / V I Q �j 1 LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME v I w�p7( E-MAIL FAX STREET ADDRESS I �,(�h S } CITY,STATE,ZIP a� `O 3� /.L PHONE !/p Ll( Zcj y" ARCHITECT/ENGINEERNAME l // LICENSENUMBER J / BUS.LIC#( COMPANY NAME E-MAIL FAX STREET ADDRESS CrrY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMII.Y PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL..!' URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO ( DESCRIPTION OF WORK / ,�� `/ C�1 TOTAL VALUATION: By my signature below,I certify to each of the following: I am the property owner or aut onzed agen e property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buil 'ng construction. I a thorize representatives of Cupertino to enter the above-ide tied property for inspection purposes. Signature of Applicant/Agent: Date: ��/��/� SUPP MENTAL INFORMATION REQUIRED oFFcEusE:o'rILx ,L,N. r. ❑k ovER THE-couNTEIi' �? Lpa�Y r F `❑ E7iPRESS .a�..`4r '.'"-,;; .v�.. ���5 �❑�STANDARD, ,t 6, e xx � rn d' ' =`❑�'LARGES "-,z.. y r r � ...:�:, x ' "�'''.,„.r� .-❑I„MAJOR,�''z) s��:. 4 4�, .� �u. t; MEPMiscApp_201 Ldoc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 10631 STOKES AVE DATE: 05/13/2015 REVIEWED BY: MELISSA APN: 326 49 015 BP#: *VALUATION: 1$13,227 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY PENTAMATION FURN/AC USE: SFD or Duplex PERMIT TYPE: i WORK REPLACE E FURNACE IN INTERIOR CLOSET&ADD N A/C UNIT IN REAR YARD SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES A/C Units (<=10K cfm) 1BREMAIR 1 # $72 Furnace, Forced-Air 1MFR=<100 1 # $143 TOTALS: $215.00 Mech.Plan Check F-001 hrs $0.00 Plunib.Plan Check Elec,Plan Checic Mech.Permit Fee: IMPERMIT Ftumb. Permit Fee: E-lec. Permit Fee: rOther 0.0 �rsMech.Insp. $48.00 Other Plumb Insp. El--t- Other Elec.Insp. Insp.Fee: Phimb. Lisp. Fee: I Elec.Insp.Fee: P2��] NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These fees are based on the prelimina information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS Lee Resolution 11-053 Ef. 7f /1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: Suppl. PC'Fee PME Plan Check: $0.00 Perinit Fee: Satppl. Insp.Fee PME Unit Fee: $215.00 PME Permit Fee: $48.00 Construction Tax: Administrative Fee: ]ADMIN $45.00 Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning Fees: Travel Documentation Fee: ITRAVDOC $48.00 i Strong Motion.Fee: IBSEISMICR $1.72 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 'SUBTOTALS: $358.72 $0.00 . TOTAL FEE: $358.72 Revised: 05/07/2015 ao 13 �u,W ki Aeffy 4 ..... . _. i 10 f, '°® -- CU ERTINO 9uildi g Department R ` MAY 13 2015 RE IE ED FOR CODE COMPLIANCE R-N\ENS Reviewed By: of CRR �c v° \<< c2` tre Lai' \° egos ti° ,;_ ��,a 3 otDe 4 of .......... E a -- GATE p EPT P CU E TINO c..