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10100195 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10804 NORTHVIEW SQ CONTRACTOR:VALLEY HEATING PERMIT NO: 10100195 &COOLING NER'S NAME: ALLEN HEYNEN 1171 N 4 TH ST DATE ISSUED: 10/27/2010 OWNER'S PHONE: 4087392601 SAN JOSE, CA 95112 PHONE NO:(408)294-6290 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB r License Class r 2 6) Lic.# 2 S5 S ya MECH F RESIDENTIAL COMMERCIAL Contractor I/e yJe Date /0A2_FZ_ �d 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 Valuation:$3018 Sq.performance of the work for which this permit is issued. Ft Floor Area: 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:31636048.00 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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR 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 CALLED INSPECTION. upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS F j indemnify and keep harmless the City of Cupertino against liabilities,judgments, /b , 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 regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: nature L��svYtf /ts Z— Date 1 Q�� All roofs shall be inspected prior to any roofimaterial being installed.If a roof is ng v _ installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: 1 hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER the following two reasons: 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) HA'LARDOUS MATERIALS DISCLOSURE 1,as owner of the property,am exclusively contracting with licensed contractors to 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 1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&Safety Code,Section 25532(a)should I store or handle hazardous declarations: Certificate of Consent to self-insure for Worker's material. Additionally,should I use equi I have and will maintain ants as pment or devices which emit hazardous defined rea Air ct Compensation,as provided for by Section 3700 of the Labor Code,for the will maintain air yMunicipalni comp)compliance with Cupertino the CuperCode,Chapter 9.12uality Management 'and performance of the work for which this permit is issued. the Health&Safety Code,Sections 25505,25533,and 25534. I have and will maintain Worker's Compensation Insurance,as provided for by I Section 3700 of the Labor Code,for the performance of the work for which this55� Date: Owner or authorized agent: �� permit is issued. I certify that in the performance of the work for which this permit is issued,1 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,1 become subject to the Worker's Compensation provisions of the Labor Code,I mi st work's hereby for which this permit isaffirm that there is a o sued(Sec.3097,Civ C.nstruction lending )for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. 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 complywith all city and county ordinances and state laws relating building construction,and hereby authorize representatives of this city to ent er don 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 CITY OF C UPERTI G FEE ESTIMATOR—13UILDIN DIVISION DATE: REVIEWED BY: ADDRESS: `VALUATION: $3,018 APN: BP#: PLAN CHECK TYPE: Alteration / Addition / Repair Mechanical Permit PENTAMATION FURN/AC xPERMIT TYPE: PERMIT TYPE: PRIMARY . SFD or Duplex USE: WORK SCOPE FEE ID gp FEES QTY UNITS APPLIANCE/EQUIP TYPE 1 # $126 Furnace, Forced-Air 1 MFR=<100 $126.00 TOTALS: 0.00 Mech.Plan Check 0.0 his $ Mech.Permit Fee: 1MPERMIT OtherMech.Insp. 0.0 hrs $42.00 Wca h. JONP. 1"ce: Plumb based on the pre in ormation available and are onl an estimate. Contact ITEMS r addn'!in o. NOTE: These ees are TY/FEE FEE ITEMS (Fee Resolution 09-051 Eff 7/1:1() EE Q Plan C'hecA Fe11: sitpp/. 1'C 1''c $0.00 PME Plan Check: Permit 1;eC: Sul�1�I. Itrsl� 1�,t> $126.00 PME Unit Fee: $42.00 PME Permit Fee: C t)}I b f f'ttt'ti()!7 l c7:i Work Without Permit. Yes (F) No $0.00 /'trrnttint <„ I" cj: oc $42.00 Travel Documentation Fee: ITRavDSelect an Administrative Item Stron�T Motion Fee: IBSEISMICR $0.50 1BCBSC $1.00 d Stds Commission Fee: BlTOTAL FEE• $211.50 SUBTOTALS: $211.50 $0.00 Revised: 10/17/2010 CITY OF C".UPERTINO 5 ITEMS OF 10 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec : Twp: Rng: Sub: Blk : Lot : APN 316:36048 . 00 DATE ISSUED. . . . . . . : 10/:27/2010 RECEIPT # . . . . . . . . . BSO )0011855 REFERENCE ID # 101 )0195 SITE ADDRESS 108 )4 NORTHVIEW SQ SUBDIVISION CITY CUPERTINO IMPACT AREA . . . . . . OWNER ALLEN HEYNEN ADDRESS 10804 NORTHVIEW SQ CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM VALLEY HEATING CONTRACTOR ATKINSON, THOMAS LIC # 141 COMPANY VALLEY HEATING & COOLING ADDRESS 1171 N 4 TH ST CITY/STATE/ZIP SAN JOSE, CA 95112 TELEPHONE (408) 294-6290 FEE ID UNIT QUANTITY FMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- --- 1BCBSC VALUATION 3 , 018 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 3 , 018 . 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 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- -- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CITY OF CUPERTINO FUR-IN-ACE/AC CUP tt'i°INO PERMIT APPLICATION FORM lol W11s APN # N� Date: rCJ/2 71 ) CP Ce 0y �,D. -" orc Building Address: <, 1 613'03,q N-,,r-f4 View _>gtfare Owner's Name: Phone#: 26 6 Contractor: Phone#: 9 OF-?41*4, Z 4� Valle' �{Puf• L Coc (�k Fax#: Contractor License#: Cupertino Business License#: Contact: Phone#: Fax#: Building Permit Info: Elect❑ Plumb ❑ Mech .� Iy' Residential 41 Commercial ❑ Job Description: 4q77 / I-,,(ri qcP K��(rCC'rvcL.r� io1 ��K! (GCCc�O't For Residential Installations: Attic F-11St floor �' 2°d floor ❑ Adhere to minimum setback requirement ❑ For Commercial Installations: Replacement same weight ❑ Additional weight(structural calcs) ❑ Structural Calculations required for new installation ❑ New installation Planning Approval Required ❑ Cost of Project: Type of Construction (Usage Class): v � Strapped ❑ On Platform ❑ Bondf d ❑ New Location ❑ Replacement ❑ Project Size: Express ❑ Standard ❑ Large EI Major❑ Valuation: t -3 15-- 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. Ito Revised 01/07/09