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12010172 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10965 DRYDEN AVE CONTRACTOR:AAA FURNACE& PERMIT NO: 12010172 AIR CONDITIONING OWNER'S NAME: MARCIA SCRIVANO 1712 STONE AVE DATE ISSUED:01/30/2012 OWNER'S PHONE: 4082097202 SAN JOSE, CA 95125 PHONE NO:(408)293-4717 ❑ LICENSED CONTRACTOR'S DECLARATIONr—BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class 2Lic.# 7655 MECH RESIDENTIAL COMMERCIAL Contractor 6M t'up4 LL Date JOB DESCRIPTION: REPLACE FURNACE IN SAME LOCATION 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:$2600 1 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:35614020.00 Occupancy Type: permit is issued. C>T APPLICANT CERTIFICATION I certify that 1 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 DAYS 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 FRO LAST CALLED 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 Issued A� / j Id b Date: ( — �v— Z granting of this permit. Additionally,the applicant understands and will comply y' !_" with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. -- RE-ROOFS: Signature / Date—1 —X-; /Z 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 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 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) 1,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 1 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 1 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 25505,2W3,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: -30 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 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. 1 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 indemnify 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 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 CITY OF CUPERTINO FEF. ESTIMATOR—BUILDING DIVISION ADDRESS: 10965 Dryden Ave DATE: 01130/2012 REVIEWED BY: RDW APN: BP#: "VALUATION: $2,600 PEMtIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/Repair PENTAhIATION FURN/AG PRIMARY USE: SFD or Duplex PERMIT TYPE: WORK Replacement of existing furnace SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Furnace, Forced-Air 1MFR=<100 1 # $130 TOTALS: $130.00 Mech.Plan Check 0.0 firs dOO Mech.Permit Fee: IMP Other Rtech.Insp. 0.0 hrs E3_L_ NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These Lees are based on the erelininary information available and are only an estimate. Contact the De t or addn'l info. ' {* l i l FEE QTY/FEE MISC ITEMS FEE ITEMS t .z ::'t =r ,' t _ .'z PME Plan Check: $0.00 PME Unit Fee: $130.00 PME Permit Fee: $44.00 Administrative Fee: ]ADMIN $41.00 Work Without Permit? d Yes 0 No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 IBSEEMICR $0.50 Select an Administrative Item rf c�'_r s'Tcls CLL tri;si =fid. :Twp°. IBCBSC $1.00 SUBTOTALS: $260.501 $0.001 TOTAL FEE: $260.50 Revised: 1/19/2012 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: 40916 e , et PERMIT# 72— OWNER'S NAME: ' 6 /L PHONE# --,;5 &-,; 7 3 1 e, ; 7 GENERAL CONTRACTOR: -" L BUSINESS LICENSE# E-SJR? ? ADDRESS: 1312- S cc'% #�L CITY/ZIPCODE: 5 L�� ,5./Z S~ *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 7ALLUBCONSTIRAACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. - ___._. __ I am not using any subcontractors: Date Signature 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 CITY OF CUPERTINO 6 ITEMS OF 12 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN 35614020 . 00 DATE ISSUED. . . . . . . : 01/30/2012 RECEIPT # . . . . . . . . . BS000015867 REFERENCE ID # 12010172 SITE ADDRESS 10965 DRYDEN AVE SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : MARCIA SCRIVANO ADDRESS 1001 LUNAAI PL CITY/STATE/ZIP KAILUA, HI 96734 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 ---------- ------------- ---------- ---------- ------ lADMIN HOURS 1 . 00 41 . 00 0 . 00 41 . 00 0 . 00 1BCBSC VALUATION 2 , 600 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 2 , 600 . 00 0 . 50 0 . 00 0 . 50 0 . 00 1MFR=<100 UNITS 1 . 00 130 . 00 0 . 00 130 . 00 0 . 00 1MPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 44 . 00 0 . 00 -----44_00 ----- 0_00 ---------- ---------- TOTAL PERMIT 260 . 50 0 . 00 260 . 50 0 . 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- ----- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408)777-3228 • FAX(408)777-3333 •building(a?cupertino.org misc CUPERTINQ >�'tCW1 �PLUIv1BING IECHAMCAL ❑ELECTRICAL ❑MISCELLANEOUS SCYPROJECT ADDRESS I('1 U�J/-�g) /��/1, A p APN k x OWNER NAME PHONE^' 7 EMAIL S'T'REET ADDRESSIC�r )C ' d p,may CITY ST nu CAFAX CONTACT NAME J V` I_L. ?C f� PHONE 4( - .2 _ „ 2- E MAII —7 i�(t 2s, �d CITYNTE �_ -n�c FAY ❑ OWNER ❑ OWNER-SUILDER ❑ OWNER AGENT )KICONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSESE TYPE BUS.LIC t COMPANY NAME STREET ADff n - I '✓ M�i CTTY�ST_A ZIP vy ARCHrrECTIENGINEER NAME r\vv LICENSE NUMBER 'v/I BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF X SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN �x STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes No FLOOD ZONE C1 Yes A N o DESCRIPTION OF WORK TT�� 2 TOTAL VALUATION: LO By my signature below,I certify to each of the wing: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I h pr ided is orrect. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws reli to buil din co ction. I authorize representatives of Cupertino to enter the ab i e-i a 'led property for inspection purposes. Signature of Applicant(Agent: - Date: SUP E IENTAL INFORMATION REQUIRED &fEPMucApp_2011.doc revised 03/16/11