15100165I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 10386 AVENIDA LN CONTRACTOR: A & H HEATING PERMIT NO: 15100165
OWNER'S NAME:
JOSE, CA 95110 PHONE NO: (408)279-0722
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
REPLACE (E) FURNACE, SAME LOCATION
License Class 0 2
Lic. # 3 0`441 7 Z
Contractor Date 1 o' 2 I S—
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:
1. 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.
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
permit is issued.
APPLICANT CERTIFICATION
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 mg
to building construction, and hereby authorize representatives of this c' o
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments, G
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply with
all non -point sou a ulations per the Cupertino Municipal Code, Section 9.18.
Signature Date L 6 —9-6— )y-
11 OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1. 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)
2. I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
1. 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.
2. 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
permit is issued.
3. 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
become subject to the Worker's Compensation provisions of the Labor Code, I
must forthwith comply with such provisions or this permit shall be deemed
revoked.
APPLICANT CERTIFICATION
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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply with
all non -point source regulations per the Cupertino Municipal Code, Section 9.18.
Signature
Date
Sq. Ft Floor Area: I Valuation: $6250
APN Number: 34245036.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
ST CALLED INSPECTION.
Date:
RE -ROOFS:
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.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owne 99 v_1
Date:l�
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 10386 avenida In DATE: 10/20/2015 REVIEWED BY: melissa
APN: 342 45 036 BP#: *VALUATION: 1$6,250
'"PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: PERMIT TYPE:
WORK replace a furnace same location
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Furnace, Forced -Air
1 MFR=<100
'3 ` ;z, f
Irk ,,
1
#
$143
PME Unit Fee:
$143.00
PME Permit Fee:
$48.00
Administrative Fee: ]ADMIN
$45.00
Work Without Permit? 0 Yes (j) No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
j $143.00
Strong Motion Fee: 1BSEISMICR
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
nictrirt etr_ )_ The.co fees are haced nn the m•elintinary infnrmatinn availahle and are nnh7 an ectinnate. Cnntart the hent fnr addn'1 infn_
FEE ITEMS (Fee Resolution 11-053 E . 7ff /1/13)
Mech. Plan Check 0.0 1 hrs $0.00
QTY/FEE
MISC ITEMS
Mech. Permit Fee: IMPERMIT
M -j #- ). 1>C;'M'it FC,.
Other Mech. Insp. 0.0 hrs $48.00
O . I,Y r
I?F is'as.i
{ S#-
'3 ` ;z, f
Irk ,,
PMEPlanCheck:
gE<
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
nictrirt etr_ )_ The.co fees are haced nn the m•elintinary infnrmatinn availahle and are nnh7 an ectinnate. Cnntart the hent fnr addn'1 infn_
FEE ITEMS (Fee Resolution 11-053 E . 7ff /1/13)
FEE
QTY/FEE
MISC ITEMS
Plan Check .lw`ee
PMEPlanCheck:
$0.00
PME Unit Fee:
$143.00
PME Permit Fee:
$48.00
Administrative Fee: ]ADMIN
$45.00
Work Without Permit? 0 Yes (j) No
$0.00
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: 1BSEISMICR
$0.81
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$285.81
$0.00 TOTAL FEE:
$285.81
Revised: 10/01/2015