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15040026CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7561 BOLLINGER RD CONTRACTOR: AIR AND PLUMBING PERMIT NO: 15040026 SYSTEMS OWNER'S NAME: LOS GATOS, CA 95032 PHONE NO: (408) 733-2000 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL REPLACE FURNACE AND RELOCATE A/C License Class 4:57 20 Lic. # 2 k.6 690,- % Contractor �� ` � J/ Date I hereby affirm AM I am licensed under the provisions f Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. 5 -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: $5200 I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 35922046.00 Occupancy Type: Section 3700 of the Labor Code, for the performance of the work for which this 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 D YS OF 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 F T CALLED INSPEC ION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the Issued by: Date: granting of this permit. Additionally, the applicant understands and will comply with all non -point source re per the Cupertino Municipal Code, Section - ROOFS: 918. >� © All roofs shall be inspected prior to anyy 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 Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of 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. 1 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 Section 3700 of the Labor Code, for the performance of the work for which this the Health & Safety Code, Sections 25505, , and 5534. permit is issued. 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 CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after making this certificate of exemption, I 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 918. Signature Date GENERAL PERMIT APPLICATION ,P MEP COMMUNITY DEVELOPMENT DEPARTMENT •BUILDING DIVISION UU 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTIN(408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.org \1�� ❑ PLUMBING ❑ MECHANICAL ❑ ELECTRICAL ❑ MISCELLANEOUS PROJECT ADDRESS 7 I IN*35L7 OWNERNAME PHONE yah _o E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX CONTACT NAME PHONE EMAIL STREETADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OwtM-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME K n &/ALICENSE NUMBER ©/ LICENSE T 70 (� BU -�j .2 Z ` COMPANY NAME / �'i E-MAIL FAX STREET ADDRESS J CITY, STATE, ZIP PHONE(tea p1 7J +�J ^ G O ARCHITECT/ENGINE NAME LICENSE NUMBER BUS. LIC #i COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD BUILDING: El or DUPLEX ❑ MULTI -FAMILY PROJECT IN WILDLAND ❑ YES ' URBAN INTERFACE AREA ❑ NO PROJECT IN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO DESCRIPTION OF WO1 LK TOTAL VALUATION: By my signature below, application and the fi ordinances and state Signature ofApplic I 6ertify to each of the following: I am the property owner or authorized agent to act on the pro a alf. I have read this Lformation I have provided is correc awe -read the Desc ' tion of Work and verify it is accurate. I agree to comply with all applicable local laws relating to bu' a s ctio I authorize rgKese tives of Cupertino to enter the abov -identified property for ins ection purposes. t/Agent: (� Date: SUPPLEMENT iF$ ANION IRED s FFICE USE'O Y00 ; IxEXPRES$ ag A -70V111 , a W rk M2,; LARGE 4A7U;R, v MEPMiscApp_201 Ldoc revised 06/21/11 goo CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION APPLIANCE / EQUIP TYPE ADDRESS: 7561 bollinger rd DATE: 04/03/2015 REVIEWED BY: Mendez UNITS APN: BP#: *VALUATION: 1$5,200 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: $72 PENTAMATION FURN/AC PERMIT TYPE: WORK replace furnace and relocate a/c SCOPE 1 APPLIANCE / EQUIP TYPE FEE ID Own' j:fi 5 sem' '� s QTY UNITS BP FEES Mech. Plan Check 0.0 hrs $0.00 A/C Units (<=10K cfm) 1BREMAIR Mech. Permit Fee: IMPERMIT 1 # $72 C)t7ie: P;um77 Ins, . Furnace, Forced -Air 1MFR=<100 11he 17h. hi p. Fee: 1 # $143 PME Unit Fee: $215.00 PME Permit Fee: $48.00 Construction Tax: Administrative Fee: ]ADMIN $45.00 Work Without Permit? ® Yes (F) No $0.00 TOTALS: T it $215.00 � V 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 Dreliminary information available and are only an estimate. Contact the Deptfor addn'1 in o. FEE ITEMS (Fee Resolution 11-053 E . 7/1113) FEE Own' j:fi 5 sem' '� s � J J Plan (.'heck Fee: Mech. Plan Check 0.0 hrs $0.00 Phanih. Ilan (.heck Elec. P/gar. Check Mech. Permit Fee: IMPERMIT 1'himb, Permu haze: Nec Permit Ve , Other Mech. Insp. 0.0 hrs $48.00 C)t7ie: P;um77 Ins, . Other flee. if? i,/ech h'sp. I`('e: 11he 17h. hi p. Fee: j lf.'C. Ms"), Fee: 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 Dreliminary information available and are only an estimate. Contact the Deptfor addn'1 in o. FEE ITEMS (Fee Resolution 11-053 E . 7/1113) FEE QTY/FEE MISC ITEMS Plan (.'heck Fee: A5uppl..1't"Fee PME Plan Check: $0.00 Permit Fee: Suppl, 1nsp Fee. PME Unit Fee: $215.00 PME Permit Fee: $48.00 Construction Tax: Administrative Fee: ]ADMIN $45.00 Work Without Permit? ® Yes (F) No $0.00 Ac1vonced I'lannin F, Travel Documentation Fee: 1TRAVDOC $48.00 Strom Motion. Fee: 1BSEISMICR $0.68 Select an Administrative Item Bldg Stds Commission. Fee: IBCBSC $1.00 a $357.68 ���� $0.00wI11FE $357.68 Revised: 02/14/2015