11010154 ' I I CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19674 VICKSBURG DR CONTRACTOR:AAA FURNACE&AIR PERMIT NO: 11010154
CONDITIONING
OWNER'S NAME: KATHY CHOLE 1712 STONE AVE DATE ISSUED:01/31/2011
VNER'S PHONE: 4082934717 SAN JOSE,CA 95125 PHONE NO:(408)293-4717
0LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
11
0Y,/,�
LICENSED
License Class 764441 Lic.# 7 Orr" REMOVE AND REPLACE FURNACE IN SAME LOCATION
Contractor 64:g- jai r/)a Q-t- Date
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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$3000
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 APN Number:36910014.00 Occupancy Type:
permit is issued. \(y
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 1 S O 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 180 DAYS OM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses whighApay accrue against said City in consequence of the JZ 1
D
granting of this pe it. ditionally,the applicant understands and will comply Issued by: ate: 1
with all -po' t so c egulations per the Cupertino Municipal Code,Section
9.18.
r / RE-ROOFS:
Signature Date 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.
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
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. I 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 re or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipme or evices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the B r Air uality Management District I
performance of the work for which this permit is issued. will maintain compliance with the upert' o nicipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Cc s 2550 33,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agent: Date:
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 CONSTRUCTION LENDING AGENCY
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
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 ARCHITECT'S DECLARATION
+emnify and keep harmless the City of Cupertino against liabilities,judgments,
s,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
b,anting 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
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: Q l07 ( q D fL PERMIT# d l
OWNER'S NAME: hole PHONE# 40
GENERAL CONTRACTOR: )::-!rn)C-CP- BUSINESS LICENSE#
ADDRESS:) L S S2 S� CITY/ZIPCODE: �
*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 SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature 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
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet c
Til
a) --
Owner/Contrr Signature Date
CITY OF CUPERTINO
5 ITEMS OF 10 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 36910014 . 00
DATE ISSUED. . . . . . . : 01/31/2011
RECEIPT #. . . . . . . . . BS000012609
REFERENCE ID # . . . : 11010154
SITE ADDRESS 19674 VICKSBURG DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : KATHY CHOLE
ADDRESS 19674 VICKSBURG DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-3322
RECEIVED FROM . . . . : AAA FURNACE
CONTRACTOR . . . . . . . : RANDO, JIM LIC # 8050
COMPANY . . . . . . . . . . : AAA FURNACE & AIR CONDITIONING
ADDRESS . . . . . . . . . . : 1712 STONE AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408) 293-4717
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- --------
1BCBSC VALUATION 3, 000 .00 1 . 00 0 . 00 1. 00 0. 00
1BSEISMICR VALUATION 3, 000 . 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 211.50 0 .00 211.50 0. 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- -------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: I DATE: REVIEWED BY:
APN: BP#: *VALUATION: 1$3,000
;'PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $126
TOTALS: $126.001 1
Mech.Plan Check0.0 hr $0.00 11h( b, 1'/urr t:'�`rec lj7,%, tlian t"hcck
Mech.Permit Fee: IMPERMIT Phan<�" 1'cvm/0""f", IiCcc`. f'�;rrrfr I-t:
Other Mech.Insp. 0.0 hrs $42.00 010"r•Plly b Ir.pLi
tJtt`i t r;iec Irrs{.
1I`cl�. fiz;��. Ce'e� Pr''zrrrth. Iiisl�, (cz; /si`t'e.It�sp. 1a2
NOTE: Theseees are based on the preliminaryin ormation available and are onl an estimate. Contact the Det or addn'l info.
FEE ITEMS (Fee Resolution 09-051 E[f. 7/1/10) FEE QTY/FEE MISC ITEMS
Plun C heck Ftie:
PME Plan Check: $0.00
Permit Fee:
Supp/. hisp Fee
PME Unit Fee: $126.00
PME Permit Fee: $42.00
(7011str-141io7 T(IX r
'Ic ouslic:te/Rc viev Fce:
Work Without Permit? 0 Yes No $0.00
Pltzrtrtn�F'e�cs.'
Travel Documentation Fee: ITRA VDOC $42.00
Strong?Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldy,Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $211.50 $0.00 TOTAL FEE: $211.50
Revised: 01/15/2011
CITY OF CUPERTINO
FURNACE/AC
0-CUPEkTINO PERMIT APPLICATION FORM
//0
APN # 261 /0 0 11411
00 Date
Building Address:
19 V7 14 J Ick Sir' 1)P-kUe_
Owner's Name: I0. Phone#:
y Chale 409- - aSS- Q3Z3
Contractor: 14 rX)QC-k -4- A-1— Phone #: �og_a93_9 7/7
Fax #: Og - 5' 3 - 67 -) /
Contractor License #: -, I Cupertino Business License#:
Contact: rDQYlC( - / Phone #: ! y .�2 j3-y7,7
Fax #: 4-69 - g - (off --7 /
Building Permit Info:
Elect ❑ Plumb ❑ Mech ['
Residential Commercial
Job Description: �erno✓� 2�is�i�� _ j,-nJ�zC2 q-- 11US4-►1/ Ale k-)
OM G l oCa�i0�
For Residential Installations:
Attic ❑ I` floor [iK 2nd floor ❑
Adhere to minimum setback requirement E9--
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: 5 000. G C) Type of Construction (Usage Class):
Strapped D On Platform Bonded New Location Replacement
Project Size: Ex ress ❑ Standard ❑ Large ❑ Major ❑ _
Valuation
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index.
Revised 01/07/09