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
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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#
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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
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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:
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SUPP MENTAL INFORMATION REQUIRED oFFcEusE:o'rILx ,L,N. r.
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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
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RE IE ED FOR CODE COMPLIANCE
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