14060112CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7480 ROLLINGDELL DR
CONTRACTOR: AAA FURNACE & AIR
PERMIT NO: 14060112
CONDITIONING
OWNER'S NAME: BRUSH CAROL A AND JAMES A
1712 STONE AVE
DATE ISSUED: 06/17/2014
OWNER'S PHONE: 4085066655
SAN JOSE, CA 95125
PHONE NO: (408)293-4717
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
J`'
�2 �U
REMOVE AND REPLACE A/C CONDENSER
License Class Lic. #q
A A- U rzuA C(Z—Date
r
ContractorA
I hereby affirm that I am licensed under the provisions of Aapter 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
Sq. Ft Floor Area:
Valuation: $4550
performance of the work for which this permit is issued.
have and will maintain Worker's Compensation Insurance, as provided for by
"ton 3700 of the Labor Code, for the performance of the work for which this
APN Number: 3593106100
Occupancy Type:
rermit 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 F 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 ROM LAST CALLED INSP CTION.
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 by: Date: /
granting of this permit. Additionally, the applicant understands and will comply
with all non- regulati s r the Cupertino Municipal Co ,Section
9 18.
RE-ROOFS:
ignature 01M, 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. 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 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 compli wit Cuperti o icipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Saf Code, Sections 5505 , and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent Date:
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
GENERAL PERMIT APPLICATION �o.
MEP
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION b j
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 - buildino a(-.CUDertino.or4MISC
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STREETADDRESS
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❑ OWNER ❑ o,% m.Bua.DER ❑ 0-MMAGEI17 .'�COMMACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ ENGINEM ❑ DEVELOPER ❑ TENKNT
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ARCHITECT/ENGINEERLAAME LICENSE NUMBER
BUS. LIC N
COMPANY NAME
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FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF SFD or DUPLEX ❑ MULTI-FAMII.Y PROJECT IN WJLDLAND ❑ YES TZO�%IN ❑YES
BUILDING: ❑ COMMERCIAL. URBAN INTERFACE AREA �1d0 NE I}'rS0
IS THE BLDG AN ❑YES
EICHLER HOME? --2—m
DESCRIPTION OF WORK l)d `G `!e Pv� s-hq
AWL
g
TOTAL VALUATION:
By my signature below, I certify to each of following: I am the property ovmer or authorized agent to act on the property ovmer £ I have read this
ided 's correct. I have read the Description of Work and verity it is accurate. I agree to comply with all applicable local
application and the information 1 have p(ding
ordinances and state laws relating to bui co truction. I u ize representatives of Cupertino to enter the above -identified property for inspection purposes.
S i °nature of Applicant/Agent:Date: I
SUPPLEME AL INFO NATION REQUIRED_
oF3cS0�- -
IWEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FM_7 FEE ESTIMATOR - BUILDING DIVISION
7480 rollingdell dr
FEE
DATE: 06/17/2014
REVIEWED BY: Mendez
IMIADDRESS:
APN:
BP#:
*VALUATION: 1$4,550
*PERMIT TYPE: Building Permit
#
$70.00
PLAN CHECK TYPE: Addition
PRIMARY
USE: SFD or Duplex
Suppl. PC Fee: Reg. ®OT
PENTAMATION
PERMIT TYPE: FURN/A
WORK
remove and replace a a/c unit
PME Plan Check:
SCOPE
$0.00
Mech. Plan Check 0.0 hrs $0.00 Plumb. Plan C'6reok
Mech. Permit Fee: IMPERMIT t'lumb. Perm;/
Other Mech. Insp.F6.61hrs$47.00 {)/laer PlumbIrra'n.
We(,h Manu_ Ilc. Phwtb. hisp. Tec:
1"ilo, Ilion Ch-cf,"
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Elf 7/1/13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
#
$70.00
Mechanical
IBREMAIR A/C Units (<=10K cfin)
Suppl. PC Fee: Reg. ®OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee -(F) Reg.
C) OT
0.0
1 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$47.00
Administrative Fee:
]ADMIN
$44.00
E)
Work Without Permit? ® Yes (F) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
0
i
Travel Documentation Fee: ITRA VDOC
$47.00
Strong Motion Fee:
1BSEISMICR
$0.50
Select an Administrative Item
Bldg. Stds Commission .Fee: IBCBSC
$1.00
YrLS
`'
$139.50
$70.00
TOTAL FEE;
$209.50
Revised: 04/01/2014