10070204 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7539 DONEGAL DR CONTRACTOR:VALLEY HEATING& PERMIT NO: 10070204
COOLING
"NER'S NAME: JAMES O&LILLIAN MITCHELL 1171 N 4 TH ST DATE ISSUED:07/30/2010
OWNER'S PHONE: 4082572759 SAN JOSE,CA 95112 PHONE NO:(408)294-6290
q LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class C �/ Lic.# s O/� MECH r RESIDENTIAL r COMMERCIAL r
r Contractor U4(IQy QG lrtk� Date ` O
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:RMV&RPLC FURNACE(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:
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:$3532
I have and will maintain Worker's Compensation Insurance,as providedd�for by
Section 3700 of the Labor Code,for the performance of the work for his
permit is issued. /'�
T APN Number:36616064.00 Occupancy Type:
APPLICANT CERTIFICATION
Icertify 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 regulations per the Cupertino Municipal Code,Section Issued-"'� Date:
9.18. �.^
- a
�'-nature mate
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)
1,as owner of the property,air 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
I 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(a)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
p Health&Safety Code,Sections 25505,25533,and 25534.
1 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 er o�auth agent: n `
Compensation laws of California. If,after making this certificate of exemption,I Date:// d
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
the above mentioned property for inspection purposes.(We)agree to save
.mify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the
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 regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
CITY OF CUPERTINO
4 ITEMS OF 4 PERMI" RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: B11:: Lot:
APN 366-16064 .00
DATE ISSUED. . . . . . . : 07,/30/2010
RECEIPT #. . . . . . . . . BS )00011034
REFERENCE ID # . . . : 10 )70204
SITE ADDRESS 7539 DONEGAL DR
SUBDIVISION . . . . . . :
CITY CUPERTINO
IMPACT AREA . . . . . . :
OWNER . . . . . . . . . . . . : JAMES 0 & LILLIAN MITCHELL
ADDRESS . . . . . . . . . . : 7539 DONEGAL DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : NICOLE MINOR
CONTRACTOR . . . . . . . : ATKINSON, THOMAS LIC # 141
COMPANY . . . . . . . . . . : VALLEY HEATING & COOLING
ADDRESS . . . . . . . . . . : 1171 N 4 TH ST
CITY/STATE/ZIP . . . : SACT JOSE, CA 95112
TELEPHONE . . . . . . . . : (408) 294-6290
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- -----
1BCBSC VALUATION 3, 532 . 00 1 .00 0 .00 1.00 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 . 00 0. 00 211. 00 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 211 .00 VISA
---------------
TOTAL RECEIPT 211 .00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- --------------------------
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY
502 FINAL PLUMBING ENERGY 503 FINAL MECHANICAL ENERGY
504 FINAL BUILDING ENERGY 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL
CITY OF CUPERTINO
19 FEE ESTIMATOR--BUILDING DIVISION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: EVALUATION: $3,532
PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY ? r j__ APPLICATION 1 RMAP6
USE: SFD or Duplex �:� 3 �a .z ,�. �: TYPE:
r
as
00
3 �
APPLIANCE/EQUIP TYPE CAPACITY FEE ID QTY BP FEES
Furnace, Forced-Air 1MFft=<100 1 $126
TOTALS: $126.00
Mech.Plan Check 0.0 hrs $0.00 `
Mech.Permit Fee: 1MPERMIT
Other Mech.Insp. 0.0 1 hrs 1 $42.00
NOTE: Theseees are based on the relimina in ormation available and are onlyan estimate. Contact the De t or addn'1 info.
7'FEE ITE7rMS (Fee Resolution 09-051 F.(: 7-'1:'Y)9) FEE QTY/FEE MISC ITEMS
PME Plan Check: $).00
f'+�t'rttrt 1 t,t-:
PME Unit Fee: $126.00
PME Permit Fee: $42.00
Work Without Permit? Q Yes No $0.00
Travel Documentation Fee: ITRA VDOC $42.00
Select an Administrative Item
Bldg, Stds Commission Fee: 1BCBSC $,1.00
SUBTOTALS: $211.00 $0.00 TOTAL FEE: $211.00
Revised: 7/27/2010
CITY O:F CUPERTINO
FURVACE/AC
CUPEk INO PERMIT APPLICATION FORM
APN# h f _\J /� Date:
Building Address: h
Owner's Name: Phone #:
Contractor: Phone#: qoo�- -" ,J 4 ltG
V� fle v Fax#: ` t'sK 1114 Y24 7
Contractor License#: Cupertino Business License#:
Contact: Phone#: 4& '� 21+
Fax#:
Building Permit Info:
Elect 1�1 - Plumb �— Mech tR
Residential XCommercial ❑
Job Description:
10C, t
For Residential Installations:
Attic Ell st floor x 2 n floor ❑
Adhere to minimum setback requirement ❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installatio:i ❑
New installation Planning Approval Required ❑
Cost of Project: Type of(construction (Usage Class):
- Vn
Strapped ❑ On Platform ❑ Bonded ❑ New Location ❑ Replacement
Valuation:
Green Building: Must attach Green Building Cheek list to this application
CITY OF CUPERTINO
FUR],ACE/AC
CITY OF
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Deserip-Jon Fee Permit Type
Group
FURNACE FURN/AC
-IPGAS RES --Residential-fbr ea gas piping system of- ---P--- ---
1-4 Outlets
1BPGAS For each gas piping system of 5 or P
more per outl A.
1BSEISMICR Residential S,Asmic B
1MECPLNCK Mechanical Plan Check M
1MFR=<100 Furnace Syst <=100k BTU install or M
relocate ea forced-air/gravity type
Ifurnace/bume:r, incl ducts/vents
attached to s-L ch appliance up to and
include 100,C 00 Btu/h
IMFRN>100 Furnace Syst> 100k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to si.ch appliance over
100,000 Btu/-i
lEPERMITFEE Electric Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
1PPERMITFEE Plumbing Pa-mit P
1TRAVDOC Travel Documentation B
1BUSLIC Business Liemse B
n.msTan caroon MDnOX10E Aiarmis) u !
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: X53D0,1 e q q PERMIT# 10 '-= -7 0 2
OWNER'S NAME: �,,,ic " PHONE # LP '2C 7 -Z S
GENERAL CONTRACTOR: w.11 e eaf � Cad', BUSINESS LICENSE# 2rj8'c t0
ADDRESS:( -7f N, -f ' SS CITY/ZIPCODE: S aK jose Y� f
*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 SUBCONT:ZACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: L
Signature Date
Please check applicable subcontractors and complete the following information:
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 Rock
Tile
Owner/Contractor Signature Date