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12090141 CITY OF CUPERTINO BUILDING PERMIT IIUILDING ADDRESS: 10505 MILLER AVE CON'1'RACI'OR:AAA FURNACE&AIR PERMIT NO: 12090141 CONDITIONING OWNER'SNAME: FIRSTBAPTISTCFIURCII 1712 STONE AVE DATE ISSUED:09/172012 OWNER'S PHONE: 4082527191 SAN JOSE,CA 95125 PRONE NO:(408)2934717 ❑ LICENSED CON IRACI'OR'S DECLARATION JOB DESCRIPTION: RF,SIDF;VI'IAI, COMM ERCIA I, 11 License Class —ao Lic.d 76 E7 /REMOVE AND REPLACE 2 CLOSET FURNACES IN SAME Contractor '\M tU(b1J�G� Date C�—�7" �Z LOCATION hereby affirm that I am licensed under the provisions of Chapterr) (commencing with Section 7000)of Division 3 of the Business&Professions Code and that in, license is in full force and effect. 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 Otis permit is issued. Sq.Ft Floor Area: Valuation:54882 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:36916026.00 Occupancy Type: permit is issued. ,\PP1,1CA,I'CFR'I'IFIGVI'ION I certify that 1 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 cit'and county ordinances and stale 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 'R.M-I". CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, �j costs,and expenses which may accrue against said City in consequence of the / /-74-3 granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: / with allnon-point source regulations per the Cupertino Municipal Code,Section 9.18. s RF:ROOFS: Signature 's Date j Z All roofs shall be inspected prior many 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: hereby affirm that l am exempt from the Contractor's License Law for one of the following two reasons: ALI,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 DAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California llealth&Safety'Code,Sections 25505.25533,and 25534. 1 will I hereby affirm under penally of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: llealth&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 llealth&Safety Code.Sectiops 25505,'_5533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this / L Owner or authorized agent: Dater 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,l 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. w'ork'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 suer upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities.judgments, ARCHITECT"S DECLARATION 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 CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 10505 Miller Ave DA'Z'E: 09117/2012 REVIP;\1'EU Rl': gs APN: BPH: 'VALUATION: $4,882 "PERMITTYPE: Mechanical Permit PLAN CIIECK TYPE: Alteration /Addition / Repair PRIMARY PE NTAMATION USE: Commercial Building PERNII.I TYPE: FURN/A WORK Remove and replace 2 closet furnaces in same location SCOPE APPLIANCE/EQUIP TYPE FEE ID Q'1'\' UNITS BP FEES Furnace, Forced-Air 1MFR=<100 2 # $266 TOTALS: $266.00 Mech. Plan Check 0.0 hrs $0.00 Plomb.Phot Check El,,,-.Plon Che,k Mech. Permit Fee: IMPERMIT Plmnh.Per•mi/Fee' 1.3- Pervait kern Other Meeh. Insp. 0.0 hrs L$45.00 Other Phuuh hrvp. Otlrer hin. Imp. bleeh.lnvp. Iv e. Planth. htgr Fee• ble'.hop. Fer NOTE': This evlintale does not inchalefeev(lite to other Deparintenty(i.e. Planning, Public Works, Fire,Sanitary Seu,er District,School District,etc.). These fees ore based on the prefinsittarl in ornaaion aeallable and are ooh'an estinnale. Contact the Dept for addn'I info. FEE ITEMS f1le Resohnion 11-053 Eff. 7/1/11) •FEE QTY/FEE MISC ITEMS Plan Check /•ie• Sappl. PC Fee PME Plan Check: $0.00 Permit Fee: Stppl. Gasp Fee PME Unit Fee: $266.00 PME Permit Fee: $45.00 Consirin-ion Toa': Administrative Fee: 1.ID,1alN $42.00 Work Without Permit? Q Yes (F) No $0.00 Ach•ancecl Planning F2:ey: Travel Documentation Pee: ITRA VDOC $45.00 A Strong Motion Fee: IBSFISMICO $1.03 Select an Administrative Item Bich", Sids Commission Fee: IBCBSC $1.00 SUBTOTALS: 1 $400.03 $0.001 TOTAL FEE: 1 $400.03 Revised: 07/01/2012 s GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION M E P :2, 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 � G`V (408)777-3228 • FAX(408)777-3333 •buildinarrJcuoerino-ooCUPERTINO \� 1 MIS_C E)PLUMBING yNLCHANICAL ELECT?LCAMISCELLANEOUS PROJECT ADDRESS 10505�s M1u�2 A\Uu 1a I ^°NI '7 �r (,Lo49 � t� da c.� Ow'NT:Z NA.ti¢ 1��.� �R�� VIrV• I I PHONE /(f(`-`,157' II II�I]EE-MUn ' STA.EET'ADDftE55 I, I'`]t�yyI 1ti11 ME �. G '�T� JCfjv�J � 'VeD14 I FAX CONTACT NAM¢ , 1 �V"/Ja�NJK PHONE 4a.2os.U1-I(� E-MA.L srn.R-r Anon:ss f (/I�1a"t� p� n 1 vu Pee C ❑OWNER ❑ OWNER-BNLOER ❑ OWNERAGENT XCOMRACTOR ❑CONTRACTORAGENi ❑ ARCHrrEC`r ❑ ENGNEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME p{.� /� j� /�J L=SE lrnz-1I I U I BUS.UC P COM@ANY NANrr �[ A l `I 1 r'r Y, Y I ^v E-MAIL YM=ADDRESS Al CH -CT/ENGJNFER NAME LICENSE NU.M ER BUS.LJC I COMPANY NAME E-MAIL FAX SfR.EET ADORESS CrrY,STATE.ZIP PHONE USE OF ❑ SFD Or Duplex ❑ Nfuld-FazOtly PROJECT'M WB.DLAND PROJEC N YMUC7URE: CorBtnercia! uttsav LYTFAFACE AREA CIYes T . Vo FLooO zoNE ❑ Yes C3 No DESCRIPTION OF WORX (`OI M 11,E Com/ U t , C VI �(�IocawV�t,3 TOTAL V,uunnou: > e By my signature below,1 cerviy to each of flowing: I am the property owner or authorized agent to act on the Property owners behalf. I have read this application and Lhe info on ve provided: correct I have read the Description of Work and verify it is accurate. l agree to comply with all applicable local ordinances and sate la relating ro wilding o macdan. I authorize repreuntatives of Cupertino to enter thea idPe1�a�'feed�7properry far inspection purposes. Signature of ApplicanUAgen. I Date: V /� SUPPLEMRSTAL INFORMATION REQUIRED `_ ""_^— EHI "�'e?vLJEILr�'T"`t°�i�+ - ;sc r N'sPi•'�� irk ME?Wuc4pp_2011.doo revised 03116111 Registration Number: Registration Date?ime: HERS Provider: ___,. - _....._ August 20,