14020057 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21170 GARDENA DR CONTRACTOR:ENERG SHIELD PERMIT NO: 14020057
OWNER'S NAME: TINA YU 370 PIERCY RD APT B DATE ISSUED:02/10/2014
OWNER'S PHONE: 4089739970 SAN JOSE,CA 95138 PHONE NO:(408)225-5544
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL
DUPLEX(21170&21172),REPLACE 2(E)FURNACES&
License Class_ Lic.# ��'�(�/Z DUCTWORK,SAME LOCATIONS.
Contractor aSE� "l% �ate 2-1 1b t
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.
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:$10000
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:32608064 00 Occupancy Type:
permit is issued.
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 180 DA 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 DA M ALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the /
0 lot/
granting of this permit. Additionally,the applicant understands and will comply su
with all non-point source regulations he Cupertino Municipal Code,Se
9 18.
-ROOFS:
Sig t 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
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)
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 store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,. 5534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized ager Dater
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
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting 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
V�
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION ,`� V
MISC
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 �v
(408) 777-3228•FAX( 8)777-3333•buildingacupertino.org \
�UPi`Et`�'tht0
❑PLUMBING IvECHAATICAL ❑ELECTRICAL []MISCELLANEOUS
PROJECT ADDRESS ^p j I APN# 070 O/
OWNIER NAME �-^ �1A r aLA PHO EMAIL
STREET ADDRESS_ 2VCS_ CITY IFAX4Q"`-K
CONTACT NAME
PHONE &M-b.I
STREETADDRESS . � � �S CITY,STATE,ZIP FAX
❑ owl,,m '❑ ORTIER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME,V1py(l
n LI SE NUMBER �2 LIC zTYPEry^� BUS.LIC#
COMPANY NAME �1 �MA
� FAX
STREET ADDRESS qz�, l (17 R. CTTY,STATE,ZIP � (3k jg t) PHOI� �( [�Q
ARCHITECT/ENGINEERNAME `R LICENSE NUMBER BUS.LIC�#G QTS trClO
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN;tLAND ❑ YES PROJECT IN
YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN R.TERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK �Q r Fz>,c-3 ,,,
2t (, o 2, Ic
09
�y K�
TOTAL VALUATION: M. D' ,
By my signature below,I certify to each of the following: I am the rty owner or authorized agent on the property mer's b d this
application and the informatio vided is.correct. I ha ead the cription of Work and verify it is accurate. I agree to comply with all applica
ordinances and state la��es r atin to b Ing construction. I a orize r s of Cupertino to enter the above-ideaantified property for inspection purposes.
SignatureofApplicant/A ent: Date: 2- P
\1-13
PLEMENTAL INFO RE UIRED � <
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1VEPAlisc-4pp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 21170 GARDENA DR DATE: 02/10/2014 REVIEWED BY: MELISSA
APN: 326 08 064 BP#: `VALUATION: 1$10,000
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION *URN/A
USE: pPERMIT TYPE:
WORK DUPLEX 21170 &21172 REPLACE E FURNACES & DUCTWORK SAME LOCATIONS.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 2 # $278
TOTALS: $278.00
E_
Mech.Plan Check 0.0
hr $0.00 1'l'uInb, 1'<an("/peck Ih/ ' PlI".n Chvk
Mech.Permit Fee: 1MPERMIT 1'i,n 1) llo'nit Fee. El'
Other Mech.Insp. 0.0 hrs $47.00 0oWP f hvmb hasp. 0 Inst).
E3__L_
Thrnth. Insp. I'1'1c'r.Imp
NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These fees are based on the prelimina information available and are only an estimate. Contact the Dept-for addh7 info.
FEE ITEMS(Fee Resolution 11-053 Ef'. 7/11131 FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $278.00
PME Permit Fee: $47.00
( cr i. lrtrc7rr=n 1-aX.
Administrative Fee: 1ADMIN $44.00
Work Without Permit? 0 Yes 0 No $0.00
�afdi%a<tzt'c.'c r;f 1 /<Iitiitn_i
/'c 1,
Travel Documentation Fee: ITRAVDOC $47.00
Strom Motion Fee: 1BSEISMICR $1.00 Select an Administrative Item
Bldp-Stds Commission Fee: IBCBSC $1.00
R NINE
7�0 ATS = $418.00 $0.001'_"' TOTAL FEE: $418.00
Revised: 01/15/2014