12030125 CITY OF CUPERTINO 13UILDING PERMIT
BUILDINCADDRE.SS: 10540STOKESAVE C-ONTRACFOR:VALLEY I[EATING& PERMIT NO: 12030125
COOLING
OWNER'S NAME: II'O YOSIIIAKI ANDIOY K'I'IZUS'1'lil? 1171 N 41TI1 ST DA'Z'E ISSUED:03232012
(OWNER'S PIIONE: 4084469534 SAN JOSE-.CA 95112 PRONE NO:(408)294-639(1
\� LICENSED COM'RAC`FOR'S DECLARATION BUILDING PERMIT INFO: 13LDC [ ELECT I- PLUD113 r
Liccnsr a Class_C �� Lie.a-.2-5-;56U
Y0
/��i v AIECIi r RESIDENTIAL COMMERCIAL
✓n C
Contractor . , Hecf.;�0-` Date 3/2 3/I z
( JOR DESCR I PT ION:REMVOE AND REPLACE EXISITNG FURNACE IN SAME.
1 he nffirnr ih:mDEnnr licensed imiidrr the pnrrisiuns of Chapter 9
(commencing with Section 7000)of Division 3 of the Business RI'rofessions LOCATION,80%FURNACE
Cute and Thal nmy license is in fail force and effect.
1 hereby affirm under penally of perjury one of the following Iwo 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 Sq.FI Fluor Area: Valuation:$3539
Section 3700 of the Labor Code,for the performance of die work for which this
permit is issued.
AI'N Number:32648005.00 Occupmtcy'I'ylie:
APPLICANT CERTIFICA'T'ION
I certify than I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and slate laws relating
to building construction,mid hereby authorize representatives ofthis city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep hamiless the City Of Cupertino against liabilities,judgments, WITHIN Igo DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM-LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,SCChaa 1 '762-` /
9.18. Issued by: J Date:
Signature te Date -
[
❑ OWNER-BIJILDF.R DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material beim installed.If a roof is
1 hereby affirm that I am exempt from the Contractor's License Law far ane of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
I,as owner of the property,or myemployees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of ApplicmC Date:
Business K Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business R Professions Code). ALL ROOF COVERINGS FO BE CLASS"A"OR BE FFER
hereby affirm under penally of perjury are of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Ilealth&Safety Cade,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ileullh&
I have and will maintain Worker's Compensation Insurance,as provided for by Sudety Care.Section 25532(x)should I store or handle ha/Ardousmaterial.
Section 3700 of the Labor Code,for the pertunnmme of the work for which this Additionally,should 1 use equipment or devices is high emit hazardous air
contaminants as defined by the Ihuy Area Air Quality Management District 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of die work I'or which this permit is issued,I shall Ilealth J Safety Code,Sections 25505,25533.and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation Imus of California. If,aller making this certificate of exemption,I (/L�'mer or ran n rzeJ age t:
become subject to the Worker's Compensation provisions of the Labor Code,I must hate: 312 3,"/2
forthwith comply with such provisions or this permit shall be deemed revoked.
CONS'IRIICI'ION 1-END WC ACENCI'--
.V'I'LIG\N'I'CI•:RTI PIG\'PION I hereby affirm that there is a construction lending agency for the performance of fork's
I certify that I have read this application and slate that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct. I agree to comply with all city 81x1 county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep hamrless the City of Cupertino against liabilitics.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 ARCI I I'I'I?CI"S DECLARATION
with all inion-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall he used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32648005. 00
DATE ISSUED. . . . . . . : 03/23/2012
RECEIPT #. . . . . . . . . : 2S000016351
REFERENCE ID # . . . : 12030125
SITE ADDRESS . . . . . : 10540 STOKES AVE
SUBDIVISION . . . . . . :
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : ITO YOSHIAKI AND JOY K TRUSTEE
ADDRESS . . . . . . . . . . : 10540 STOKES AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-1235
RECEIVED FROM . . . . : VALLEY HEATING & CO
CONTRACTOR . . . . . . . : JEFF AND CINDY FAULKNER LIC # 141
COMPANY . . . . . . . . . . : VALLEY HEATING & COOLING
ADDRESS . . . . . . . . . . : 1171 N 4TH ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95112
TELEPHONE . . . . . . . . : (408) 294-6290
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- --------- --- -- ---------- ----------
-ADMIN HOURS 1 .00 41. 00 0. 00 41. 00 0. 00
1BCBSC VALUATION 3, 539 . 00 1. 00 0. 00 1 . 00 0. 00
1BSEISMICR VALUATION 3, 539 . 00 0. 50 0. 00 0 .50 0. 00
1MFR=<100 UNITS 1 . 00 130. 00 0. 00 130 .00 0. 00
1MPERMITFE FLAT RATE 1 . 00 44 . 00 0. 00 44 .00 0. 00
1TRAVDOC FLAT RATE 1 . 00 44 . 00 0. 00 44 .00 0 . 00
--------- --------- ---------- ----------
TOTAL PERMIT 260.50 0. 00 260 .50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 260 .50 #23401
---------------
TOTAL RECEIPT 260 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
172 ADDRESS: 10540 stokes ave DATE: 03/23/2012 REVIEWED Bl': larrys
APN: BP#: 'VALUATION: $3,539
*PERM I'1 TVPE: Mechanical Permit PLAN CHECK TYPE: Alteration I Addition / Repair
PRIMARI' SFD or Duplex PENTAMATION FURN/AC
USE: pPERMITTYPE:
WORK remove and replace existing furnace in same location 80% furnace
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $130
F-
TOTA LS: $130.00
Mech. Plat Check 0.0 hrs $0.00 Plumb. Plan Check Dec. Plan Check
Mech. Permit Fee: I MPERMIT Phunh.Permit tee: rlac. Permit Fee:
Other Mech. Insp. 0.0 hrs $44.00 Other Plumb Insp. El I
Other Elec.lay.
Mock lnsp. Fee.: Plumb. brag.pee: Elce.Insp..Fee:
NOTE: This estimate does not include fees due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc.). Theve fees nre'hosed on the prelindnarw information available and are on1w,an evti nate. Concoct the De ! or addn'I info.
FEE ITEMS (Fce Resolution 11-053 E0: 7/1/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
.Stipp/. PC Fre
PME Plan Check: $0.00
Pentnit Fee:
Sapp/. bap lee
PME_ Unit Fee: $130.00
PME_ Permit Pee: $44.00
Consawetion Tax:
Administrative Fee: MDAIIN $41.00
Work Without Permit? O Yes 0 No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRdVDOC $44.00
A
SlfonR Motion Fee: IBSEISAfICR $0.50 Select an Administrative Item
131d¢Sids Commission Fee: IBCBSC $1.00
SUBTOTALS: $260.501 $0.00 TOTAL FEE: $260.50
Revised: 1/19/2012