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11040176 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 6367 BLACKWOOD DR CONTRACTOR:O C MC DONALD CO INC PERMIT NO: 11040176 OWNER'S NAME: MARGARET KELM 1150 W SAN CARLOS ST DATE ISSUED:04/26/2011 OWNER'S PHONE: 4082571239 SAN JOSE,CA 95126 PHONE NO:(408)295-2182 L LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT f— PLUMBr License Class Lic.# 2—(ZS MECH RESIDENTIAL f— COMMERCIAL Contractor n.C� Me'"bc v>l.(Cf Date 11 I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE EXISTING FURNACE&ADD NEW A/C UNIT (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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$4500 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. APN Number:36918003.00 Occupancy Type: APPLICANT CERTIFICATION 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 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 indemnify 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 with all non-point source r guI tions er the Cupertino Municipal Code,Section Issued — Date: 9.18. Signature f Date 1t RE-ROOFS: OWNER-BUILDER DECLARATION 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 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 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 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 the hazardous materials requirements under Chapter 6.95 of the 1 have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I 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(x)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for 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 [certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Owner or h nt• Compensation laws of California. If,after making this certificate of exemption,I 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 and keep harmless the City of Cupertino against liabilities,judgments, costc and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION gi ,of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. wi,. _i non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36918003 . 00 DATE ISSUED. . . . . . . : 04/26/2011 RECEIPT #. . . . . . . . . : BS000013290 REFERENCE ID # . . . : 11040176 SITE ADDRESS . . . . . : 6367 BLACKWOOD DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : MARGARET KELM ADDRESS . . . . . . . . . . : 6367 BLACKWOOD DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : WANDA WILSON CONTRACTOR . . . . . . . : MCDONALD, JAMES V LIC # 268 COMPANY . . . . . . . . . . : O C MC DONALD CO INC ADDRESS . . . . . . . . . . : 1150 W SAN CARLOS ST CITY/STATE/ZIP . . . : SAN JOSE, CA 95126 TELEPHONE . . . . . . . . : (408) 295-2182 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 4, 500. 00 1. 00 0. 00 1.00 0. 00 1BREMAIRHA NO.UNITS 1.00 63 .00 0. 00 63 .00 0. 00 1BSEISMICR VALUATION 4,500 .00 0 .50 0. 00 0 .50 0. 00 1MFR=<100 UNITS 1.00 126. 00 0. 00 126 .00 0. 00 1MPERMITFE FLAT RATE 1.00 42. 00 0. 00 42 .00 0. 00 1TRAVDOC FLAT RATE 1 .00 42. 00 0. 00 42 .00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 274 .50 0. 00 274 .50 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 274 .50 MC --------------- TOTAL RECEIPT 274 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 6367 blackwood dr. DATE: 04/26/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$4,500 Y PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/Repair PRIMARY SFD or Duplex PENTAMATION FURN/AC USE: PERMIT TYPE: WORK replace existing furnace add new A/C unit SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES A/C Units (<=10K cfm) 1BREMAIR 1 # $63 Furnace, Forced-Air 1MFR=<100 1 # $126 TOTALS: 1 $189.00 Mech.Plan Check0.0 hrs $0.00 - - Mech.Permit Fee: 1MPERMIT Other Mech.Insp. 0.0 hrs $42.00 NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addh 7 info. FEE ITEMS (Eee Resolution 09-051 hff '-1.10) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $189.00 PME Permit Fee: $42.00 Work Without Permit? Q Yes E) No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 i Strom Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg,Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $274.50 $0.00 TOTAL FEE $274.50 Revised: 04/01/2011 Building Department City Of Cupertino LM 10300 Torre Avenue Cupertino,CA 95014-3255 Telephone: 408-777-3228 U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST 'e Olt oe JOB ADDRESS: (63G-7 Ma ,kI,,w0d PERMIT# 7 OWNER'S NAME: K., kw% PHONE# HO-9 2-T5--2,10q2- GENERAL `t--Z10q2-GENERAL CONTRACTO : V-C BUSINESS LICENSE# 1 7 21 ADDRESS: 1150 Vtil. mac,.. t; SS c 5 j (o CITY/ZIPCODE: t V 5`C� *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCON ACTO S HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. r, I am not using any subcontractors: 4 f ze11� Sign ure Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum /Wood Glass / Glazing Heating 01C. Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333•building(cDcupertino.org MISC CUPERTINO `PLUMBING 2MMCHANICAL 2ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS , L) �' APN# �� I Ci OWNER NAPHONE E-MAIL V ME STREET ADDRESS CITY,STATE,ZIP FAX Cv Fo C C �� CONTACT NAME PHONE E-MAIL STREET ADDRESS CrrY,STATE,ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME ` LICENSE n ) . 7LICENSE TYPE BUS.LIC# ` rf f� / GS COMPANY NAMEAX 'C - C `��'� EMAIL 2-cls--- 064C STREET ADDRESS CITY,STATE,ZIP PHONE IIST Vj awCF 1� n, e (* 512 -i ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE SE OF SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUC'ITJRE: ❑ COmIIlercial URBAN DrI'EMACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORK � t v1° a"-{ Zeo(,Ict. . 42vrVt C-e— i v.. c-'O c- Add L 4n 1n 23 TOTAL VALUATION: ��r��. RECEIBY �ft By my signature below,I certify to each of the f Il ng: 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' is e I ve 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 ' cons authorize representatives of Cupertino to enter the abov ideUt d property for inspection purposes. Signature of Applicant/Ager Date: 2 l SUPPLEMENTAL TION REQUIRED MEPMiscApp 2011.doc revised 03/16/11