The URL can be used to link to this page

12020114 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18465 CHELMSFORD DR CONTRACTOR:HUSSEY BROS INC PERMIT NO: 12020114 OWNER'S NAME: WASILCZYK THOMAS J 903 GEORGE ST DATE ISSUED:02/27/2012 OWNER'S PHONE. 4082525740 SANTA CLARA,CA 95054 PHONE NO:(408)733-6360 Ef" LICENSED CONTRACTOR'S DECLARATIONF- BUILDING PERMIT INFO: BLDG ' ELECT PLUMB ' License Class LicA f--- MECH ' RESIDENTIAL ' COMMERCIAL Contractor3. Date I hereby affirm That I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE FURNACE AT SAME LOCATION (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: (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:$2700 1 have and will maintain Worker's Compensation Insurance,as provided for by Section 3 700 of the Labor Code,for the performance of die work for which this Permit is issued. APN Number:37522046.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnity and keep harmless the City of Cupertino against liabilities.judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply ii-point s-- e gala s per the Cupertino Municipal Code,Section with all no a s Issued Ill! oo,04-� s ee r gu" Signature- Da ------- RE-ROOFS: ❑ OWNER-BUILDER DECLARATION All roots shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining all inspection,I agree to remove all new materials for I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work,and tile structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Las owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read tile hazardous materials requirements under Chapter 6.95 of the I have sand will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Compensation.as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,ac provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,tbr the performance of the-work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&Saf , 'ode.Sections 2.5505,25533,and 25534. 1 certify that in the performance of the work for which this permit is issued,I shall not ern ployany person in any manner so as to become subject to the Worker's Own or a onipensa-tion laws of California. If,after making this certificate of exemption,1 Date: 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. �CONSTRUCTION LENDING AGENCY' I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save indemnify arid keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regula(ii-xis per tile Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . 37522046 . 00 DATE ISSUED. . . . . . . : 02/27/2012 RECEIPT #. . . . . . . . . BS000016111 REFERENCE ID # . . . 12020114 SITE ADDRESS . . . . . 18465 CHELMSFORD DR SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : WASILCZYK THOMAS J ADDRESS . . . . . . . . . . : 18465 CHELMSFORD DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : HUSSEY BROS. , INC CONTRACTOR . . . . . . . : HUSSEY, STEVE LIC # 20758 COMPANY . . . . . . . . . . : HUSSEY BROS INC ADDRESS . . . . . . . . . . : 903 GEORGE ST CITY/STATE/ZIP . . . : SANTA CLARA, CA 95054 TELEPHONE . . . . . . . . : (408) 733-6360 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ------- IADMIN HOURS 1 .00 41.00 0 .00 41 .00 0 .00 1BCBSC VALUATION 2, 700 .00 1 . 00 0 . 00 1.00 0. 00 1BSEISMICR VALUATION 2 ,700 .00 0 .50 0 .00 0 .50 0 . 00 1MFR=<100 UNITS 1 .00 130 . 00 0 . 00 130 .00 0 . 00 1MPERMITFE FLAT RATE 1 .00 44 .00 0 .00 44 .00 0 . 00 1TRAVDOC FLAT RATE 1 .00 44 . 00 0. 00 44 .00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 260 . 50 0 . 00 260 .50 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 260 . 50 #35515 --------------- TOTAL RECEIPT 260 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 18465 chelmsford dr. DATE: REVIEWED BY: bobs. APN: I BP#: *VALUATION: 1$2,700 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAD ATION FURN/AC USE: PERMIT TYPE: WORK replace furnace at same location. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Furnace, Forced-Air 1MFR=<100 1 # $130 TOTALS: $130.00 Mech. Plan Check 0.0 hrs $0.00 ;.. Meeh.Permit Fee: I MPERMIT Other Mech. Insp. 0.0 hrs $44.00Li Lj NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These ees are based on the prelimina information available and are onL are estimate. Contact the De t Lor addn'l info. FEE ITEMS (Fee Resolution 11-053E .' 7/1/1.11 FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $130.00 PME Permit Fee: $44.00 El :1 Administrative Fee: ]ADMIN $41.00 Work Without Permit'? 0 Yes (F) No $0.00 Travel Documentation Fee: 1 TRA FDOC $44.00 Strong Motion Fee: 1 BSEISMICR $0.50 Select an Administrative Item Bldg Suis Commission Fee: 1BCBSC $1.00 7 SUBTOTALS: $260.50 $0.00 TOTAL'FEE: $260.50 Revised: 1/19/2012 IV-4 5 V 1 --)-�_-) -.;)L c!) j 1 % GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 2 (408)777-3228• FAX(408)777-3333•buildin cu ertino.org misc CUPERTINO ❑PLUMBING CHANICAL/ ❑ELECTRICAL [:]MISCELLANEOUS PROJECT ADDRESS (� / S_ C_ p I _/O r APN# ! OWNER NAME t o v1 `I^ Z PHONE 0 1 �-�_ Lf 1) E-MAIL STREET ADDRESS w CIT , STATE,ZIIP LJ FAX �g4l�S C�.e�l�•s erd �c . �er�i�u gSv CONTACT NAME 4ev V e PHONE�0 8 7n3-L3G0 E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME H s e LICENSE NU�BER��L FICEeE TYP BUS LIC# _-77-0 COMPANY NAME E-MAILL FAX YOd 73 2--S-Q/_Q STREET ADDRES CI STAT ,ZIP PHONE �1 /Y/ �0 Geo r e 3 rc.wti Cl�..r�c C 9�osy �D�'�33—G3Go ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE.ZIP PHONE USE OF *'SPD or DUPLEX ❑ MULTI-FAMILY 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 WORK8'Q/Q vo Irtplact oC�rtte( Air' e�/ se-se-&—ti.rha •.�Ce _— SaSI'zt 5 � � �oec��o� /v C F lC TOTAL VALUATION: '0 X7 00, RECEIVED BY: By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have prov ed 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 build c truction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: 1< SUPPLEMENTAL INFORM ATPN REQUIRED FFICE USE ONLY W OVER-THE-COUNTER 0. F ❑ EXPRESS x ❑ STANDARD U Z ❑ LARGE a a ❑ MAJOR MEPMiscApp_2011.doc revised 06/21/11