13050013 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11629 BIRCH SPRING CT CONTRACTOR:VALLEY HEATING& PERMIT NO:13050013
COOLING
OWNER'S NAME: LI SHEN Y AND SUSAN S 1171 N 4TH ST DATE ISSUED:05/02/2013
OWNER'S PHONE: 4082530184 SAN JOSE,CA 95112 PHONE NO:(408)294-6290
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIALE]
License Class C-,2e) Li..# t'tr5g6 REPLACE(E)FURNACE(GARAGE AREA)&(E)A/C UNIT
(SIDE YARD).REPLACE(E)WATER HEATER WITH(1)
Contractor ✓ j ` _ Date - `r TANKLESS,SAME LOCATION&REPLACE GAS LINE FOR
I hereby affirm that I am license 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:$11628
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:36654079.00 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 DAYS OF PIWHT 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 180DA LAST LED 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 S Z
granting of this permit. Additionally,the applicant understands and will comply ssued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
' / .S/�1 RE-ROOFS:
Signature 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
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. Iwill
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 25505,225534,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent:_ Date•552//
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.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
1�
GENERAL PERMIT APPLICATION Q� MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 h
MI�UPERTtM4 (408)777-3228•FAX(408)777-3333•buildinq@cupertino.org M SC
❑PLUMBING 2KECHANICAL ❑ELECTRICAL / /❑MISCELLANEOUS
PROJECT ADDRESS �/t �;re4 �. APN# �I /_ /_ 5 V 6
OWNER NAME L PHONE 0 M V r/ E-MAIL_( V
SLzzt
STREET ADDRESS CITY,STATE,ZIP FAX
111,929 S Fi C
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP FFAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR kCONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER 25�5Y� LICENSE TYPE BUS.LIC#
v 11 - c-26lY
COMPANY NAME It E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
71 t 5f. 5d" bs 451(2
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL, FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
RZ - /oeq firms ° F menace
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TOTAL VALUATION: �(/_7?—
my signature below,I certify to each of the following: 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 have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to bui ' g c ctio I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: q</,2613
SUPPLEM. L INFORMATION REQUIRED '
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MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 11629 BIRCH SPRING CT DATE: 05/02/2013 REVIEWED BY: MELISSA
APN: 366 54 079 BP#: *VALUATION: 1$11,628
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: FURN/A
WORK REPLACE E FURNACE GARAGE AREA & E A/C UNIT SIDE YARD). REPLACE E WATER
SCOPE HEATER WITH (N)TANKLESS, SAME LOCATION & REPLACE GAS LINE FOR WATER HEATER
11,Adem
.__.. 'Gv.....i. S�.. .. .. ..
Mech.Plan Check 0.0 hrs $0.00 Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check
Mech.Permit Fee: IMPERMIT Plumb.Permit Fee: IPPERMIT Elec. Permit Tee:
Other Mech.Insp. 0.0 hrs $45.00 Other Plumb Insp. 0.0 hrs $45.00 Other Elec.Insp.
E17L--
A,fech.Insp.fee: Plumb. Insp.Fee: Elcc.Insp,Pee:
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS(Fee Resolution 11-053 Eff. 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 # Mechanical
Suppl. PC Feer (j) Reg. 0 OT 0.0 hrs $0.00 $133.00 1MFR=<100 I Furnace,Forced-Air
PME Plan Check: $0.00 F-T-1 # Mechanical
Permit Fee: $0.00 $67.00 1 1BREAmm A/C Units(<=1OK cfm)
Suppl. Insp.Fee.0 Reg. ®OT 0 0 hrs $0.00 0 # Plumbing
PME Unit Fee: $0.00 $27.00 IPRWHEATR Water Heater
PME Permit Fee: $90.00 0 # Plumbing
Construction :Tear: $67.00 IPGASRES Piping,Gas<=4 Outlets
Administrative Fee: IADMIN $42.00
Work Without Permit? 0 Yes 0 No $0.00 E
Advanced Planning Fee: $0.00 Select a Non-Residential
Travel Documentation Fee: ITRAVDOC $45.00 Building or Structure
i
Strong Motion Fee: IBSEISMICR $1.16 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
$179.16 $294.00 $473.16
Revised: 04/29/2013
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