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13070124 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19660 VICKSBURG DR CONTRACTOR:RELIABLE AIR PERMIT NO:13070124 MECHANICAL OWNER'S NAME: SAN JOSE,CA 95136 PHONE NO:(408)266-7267 LICENSED CONTRACTOR'S.DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIALEI License Class Lie.# L ADD(N)A/C UNIT IN SIDE YARD AREA Contractor ��"P_ Date I hereby affirm that I am licensed under the provisions o Chap r 9 (commencing with Section 7000)of Division 3of 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:$8500 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:36910015.00 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 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 S ALLED 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 I b Date: granting of thi tionally;the applicant understands and will comply with al n-point source lation per a Cupertino Municipal Code,Section 9.11. RE-ROOFS: Sign Date All roofs shall be inspected prior to any roofing material being installed.If 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) 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 I have and will maintain aCertificate 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 B Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compli. [f the C ertino Mu ' ipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&=agen n 5505,2 3 , td 2553: Section 3700 of the Labor Code,for the performance of the work for which this Owner or autDate-vjs 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 9.18. Signature Date GENERAL PERMIT APPLICATION :; COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION ^� 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 {408)777-3228•FAX(408)777-3333•buildingCcilcupertino.org M" . misc cuptkTINC} / Q PLUMBING' , ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANE/OUS PROJECT ADDRESS AIN# SIG Irn OWNER NAME' ,':. � FAX CONTACT NAMEI C Y '�l� Q 6 r PHO GI `� /+� EMAIL STREET ADDRESS t ,� V�V/^ - -/� CITY,STATE,ZIP FAX ❑ OWNER ❑ OWNER-BUII.D<ER—\:/\❑ OWNERA JGENT+YT� CONTRACTOR ❑CONTRACTOR AGENT ❑ \ARcHrmcr ❑ IENmmm ❑ -DEVELOPER ❑'TENANT .. CONTRACTOR NAME , /� i ,n LICENSE NUMBER�SC�lr () 7CENSETYPr-aDBUS.LIC# COMPANY NAME -� w lei-l/I/` E-MAIL r 1 1��L�CJ FAX STREET ADD ^ CITY,STATE,ZIP ^ / PHONE[la 1 / ARQEITECT/ENGINEER NAME /I / n LICENSE NUMBER BUS.LIC# COMPANY N7vy AME FAX STREET ADDRESS I CITY STA E Z PHONE USE'.OF i ❑SFD o[DUPLEX ❑'MOI Ln-FAMILY PRO]ECT IN WII.D ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILD,INCr ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTIONpFV4 ii . - .. WIA i I it I; I I. til �� ul� TOiq lu�i VALUATION !! '' ! g By my signature,below;;I certify„f eac ollowing: I am the property owner or authorized agent to act on the property owne s £ I have read this ;application and the>n#oSinatio ve provi is correct I read the Description of Work and verify it is accurate. agree comply with all applicable local: ordinances and:state Laws hngto. uild' construe n. I t riz repr9sentatives of Cupertino to enter the above-id ntified ope for inspection purposes. I ;I 'Signature ofAp�hcant/A 'y Date: SUPPLEMENTAL INFORMATION REQUIRED -^ �7a '” I �I 115• � ��i I'' I I I I I I• l I I, MEPMiscApp_201 Ldoc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION JIM ADDRESS: 19660 VICKSBURG DR DATE: 07/19/2013 REVIEWED BY: MELISSA APN: 36910015 BP#: "VALUATION: $8,500 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex PENTAMATION FURN/AC USE: p PERMIT TYPE: WORK ADD N A/C UNIT IN SIDE YARD AREA SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES A/C Units (<=10K cfm) 1BREMAiR 1 # $70 TOTALS: $70.00 Mech.Plan Check 0.0 hrs $0.00 Plumb.Plan Check Flee.Plan Check Mech.Permit Fee: 1MPERMIT Plumb.Permit Fee: Elec.Permit Fee: Other Mech.Insp. o-01 .0 hrs $47.00 Other Plumb Insp. Other Elec,Insp. 1fech.Insp. Fee: Plumb. lash.Fee: Elec.Insp.Fere: NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . These fees are based on the preflinina information available and are only an estimate Contact the Dept-for addn'1 info. FEE ITEMS (Fee Resolution 11-053 E . 7/1/12) FEE QTY/FEE MISC ITEMS Plan Check 1,ee. ;Sulppl. PC Fee PME Plan Check: $0.00 Per1"nit.Fee: .Suppl. Insp Fee PME Unit Fee: $70.00 PME Permit Fee: $47.00 Consortction :Tint: Administrative Fee: IADMIN $44.00 Work Without Permit? ® Yes (E) No $0.00 Advanced Planning Fees: - Travel Documentation Fee: 1TRAVDOC $47.00 Strong Motion Fee: 1BSEISMICR $0.85 Select an Administrative Item. Bldg Stds Commission Fee: 1BCBSC $1.00 $209.85 $0.00m A -,t $209.85 Revised: 07/01/2013 PLOT PLANTS I LC'A 14 r-0 r K— CHECKED BY I q�V� V S 10L7�- (�� DATE /4 2,6 t3 rill PN: 9 t v 015; ANNING"DEPT. �a �p .2 dal DATE Y BLDG. DEPT. CUPERTINO COMMUNITY DEVELOPMENT DEPARTMENT 4 wilding Department BUILDING DIVISION-CUPERTINO zp� JUL 19 2013 APPROVED This set of plans and specifications MUST be kept at the REVIEWED FO lob site during construction. It is unlawful to make any R CODE COMPLIANCE changes or alterations on same,or to devir'i:e Reviewed By. ` —� therefrom, without approval from the Building Official The sn a ' of this plan and specifications SHALL NOT CN 8 held to permit proval of the viol4 on o ity Ordinance or State Law. G '1 N ' ADD CN DA TE PE MIT NO. 16 Ural I'�o t2y '6 .51 YA"a-b )'-ae 4 ar-5 �I BioOFFICE p� r