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11030151BUILDING ADDRESS: 10240 DUBON AVE CITY OF CUPERTINO BUILDING PERMIT I CONTRACTOR: RELIABLE AIRI PERMIT NO: 11030151 MECHANICAL ER'S NAME: JANET GEIGER 13670 D CHARTER PARK DR I DATE ISSUED: 03/31/2011 I OWNER'S PHONE: 4083566501 ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic. # �f QQQ t ` Contractor A` -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. 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 permit is issued. APPLICANT CERTIFICATION 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, 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 a Ju rce regulations per the Cupertino Municipal Code, Section 9. �[r Date ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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. 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 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 l\ 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. APPLICANT CERTIFICATION 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 t- ' -ilding construction, and hereby authorize representatives of this city to enter :he above mentioned property for inspection purposes. (We) agree to save in",.nnify and keep harmless the City of Cupertino against liabilities, judgments, 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 9.18. Signature Date SAN JOSE, CA 95136 PHONE NO: (408) 266-7267 BUILDING PERMIT INFO: BLDG ELECT F PLUMB r— MECH r RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION: REPLACE EXISTING FURNACE AT UTILITY CLOSET LOCATION Sq. Ft Floor Area: I Valuation: $2500 APN Number: 34214049.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by' Date: 9 .....3/_. C; RE -ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(x) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the ty Co ,Sections 25505, 25533, and 25534. Date: CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of Aork's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional 'j CITY OF CUPERTINO FOR -07 F.CTUWATOR—RITILDING DIVISION im,ADDRESS: 10240 dubon ave. QTY/FEE DATE: 03/31/2011 REVIEWED BY: bobs. BP FEES APN: BP#: "VALUATION: 1$2,500 °PERMIT TYPE: Mechanical Permit 1 PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Du lex USE: p PENTAMATION FURN/AC PERMIT TYPE: WORK replace existing furnace at utility closet location SCOPE APPLIANCE / EQUIP TYPE FEE ID QTY/FEE QTY UNITS BP FEES Furnace, Forced -Air 1MFR=<100 1 # $126 F71 PME Unit Fee: $126.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes E) No $0.00 TOTALS: Travel Documentation Fee: ITRA VDOC $126.00 Strom Motion Fee: 1BSEISMICR Mech. Plan Check 10.0 1 hrs $0.00 Mech. Permit Fee: IMPERMIT Other Mech. Insp. 1 0.0 1 hrs 1 $42.00 7VnTF• Th- Enna nro hacod nn tho nroliminary infnrmatinn availahlo and aro aniv an oetitnnte_ Cantart the Dent for addn'1 info. FEE ITEMS (Pee Resolution 09-05.1 T'[,10) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 F71 PME Unit Fee: $126.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes E) No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 Strom Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item BldgStds Commission Fee: 1BCBSC $1.00 1 SUBTOTALS: $211.50 $0.00 TOTAL FEE. $211.50 Revised: 01/15/2011 5 ITEMS OF 5 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 34214049.00 DATE ISSUED.......: 03/31/2011 RECEIPT #.........: BS000013055 REFERENCE ID # ...: 11030151 SITE ADDRESS .....: 10240 DUBON AVE SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ...... OWNER ............: JANET GEIGER ADDRESS ..........: 10240 DUBON AVE CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: PHILLIP A DORE CONTRACTOR .......: PHIL DORE LIC # 32027 COMPANY ..........: RELIABLE AIR MECHANICAL ADDRESS ..........: 3670 D CHARTER PARK DR CITY/STATE/ZIP ...: SAN JOSE, CA 95136 TELEPHONE ........: (408) 266-7267 OPERATOR: patg COPY # : 1 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL ---------- 1BCBSC ------------- VALUATION ---------- 2,500.00 ---------- 1.00 ---------- 0.00 ---------- 1.00 ---------- 0.00 1BSEISMICR VALUATION 2,500.00 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 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT AMOUNT --------------- 211.50 --------------- 211.50 VOICE ID DESCRIPTION -------- ---------------------------- 505 FINAL ELECTRICAL 508 FINAL MECHANICAL REFERENCE NUMBER -------------------- #5026 VOICE ID DESCRIPTION -------- ---------------------------- 507 FINAL PLUMBING CITY OF CUPERTINO CITY OF CUPERTINO FURNACE/AC PERMIT APPLICATION FORM 1103 0i,Di APN #1 � i 1 —I 9 Date: 31;2 � Building Address:10zqb k ave, Owner's N'n n 7 1 I tX• Y P17ef#t Contractor: Phone`#:: L( CQ,� ►� i'1�C�� -� C�- Fax #: Ve 796 Contractor License #: Cupertino Business License #: Contact: Phone #: Phil 00�t Fax#: Building Permit Info: Elect [l'�' Plumb [l--�- Mech Residential Commercial Job Description: �--. t fiV 4✓v C -e For Residential Installations: Attic ❑ IS, floor % 2°d floor ❑ Adhere to minimum setback requirement ❑ For Commercial Installations: Replacement same weight ElAdditional weight (structural calcs) ❑ Structural Calculations required for new installation ❑ New installation Planning Approval Required ❑ Cost of Project: I e C3 Type of Construct (Usage Class): StrappedEl On Platform El Bonded ET New Location Replacement Er Project Size: Express cl--�-StandardEl Large ❑ MajorEl 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. neviseu viiviiVY CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: i taLi t? PERMIT # �j 0 50 OWNER'S NAME: PHONE # 6 GENERAL CONTRACTOR: ��.r• BUSINESS LICENSE # ADDRESS: iY6&t) S CITY/ZIPCODE: 'Our municipal code requires all businesses working in the city to have a City of Cupertino business ucense. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND NT CTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not usingsubcontractors: �� "'_ � �— any Signature Date Please check applicable subcontractors and complete the following information: Owner / Contractor Signature Date 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