13010114CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19661 AUBURN DR CONTRACTOR: VALLEY HEATING & PERMIT NO: 13010114
COOLING
OWNER'S NAME: COHEN ARMAND L 1171 N 4TH ST DATE ISSUED: 0122/2013
OWNER'S PHONE: 4083989443 SAN JOSE, CA 95112 PHONE NO: (408)2946290
Ip LICENSED CONTRACTOR'S DECLARATION
License Class L-2-0 Lic. # - 2 6F546
I
Contractor VQ(�rL —Jee; .ra Date jL22t113
I hereby affirm that I am licensed 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.
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
permit is issued.
APPLICANT CERTIFICATION
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
indemnify and keep harmless the City of Cupertino against liabilities, 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
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.-_/�_,rI �
Signature />h/Lf1cI�I)ate 1/� Z11t 3
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
I, w owner of the property, or my employees with wages w 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
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and Will maintain a.Certifrcate 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
Section 3700 of the Labor Code, for the performance of the work for which this
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
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city andcountyordinances 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
indemnify and keep harmless the City of Cupertino against liabilities, 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
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18. -
Date
JOB DESCRIPTION: RESIDENTIAL
REPLACE (E) FURNACE, SAME LOCATION
Sq. Ft Floor Area: I Valuation: $3680
APN Number: 31632025.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS "ERMIT ISSUANCE OR
180 DAYSF PST CALLED INSPECTION.
:d a e: 22 j
RE -ROOFS:
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.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 255333,, and 25534.
Owner or authorized agent:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used m public records.
Licensed
CITY OF CUPERTINO
WWW W omrrn,r ♦ m!\D WHIT T7Nf_' INVi4ZTl1N
Mech. Plan Check 0.0 Ins $0.00 Plumb. Plan Check Elec. Plan Check
- - Mech..Permlt Fee: 1AIPERAIl Plumb. Penni/ Fee: Elec. Perma Fee:
Oth71avp.
. Insp. 0.0 hrs $45.00 Ocher Plumb Insp.L—i L—] Li
Other Elco. Insp. -
Adecee: Plumb.hap. Fee.' Dec Insp. Fee:
NOTE: This estimate does not inchede fees due to other Departments (La Planning, Public Works, Fire, Sanitary Sewer Distric0 Schoe
- U15a9Ci e[C:. I neJe eeJ uro uuoca ws a^c • c.u,x..u.
FEE ITEMS (Fee Resolution 11-053 Eff' 7/1112)
... o.....»..... ... _......__
FEE
_._._ _--
QTY/FEE
_.-- ._- __-_
MISC ITEMS
Plan Check Fee:
ADDRESS: 19661 AUBURN DR
DATE: 01/22/2013
REVIEWED BY: MELISSA
0.0
APN:316 32 025
BP#:
`VALUATION: -
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration /Repair
PRIMARY SFD Or DupleXPENTAMATION
$0.00
PERMIT TYPE: FURN/AC
USE:
hrs
$0.00
PME Unit Fee:
WORK
REPLACE E FURNACE SAME LOCATION
$45.00
SCOPE
Mech. Plan Check 0.0 Ins $0.00 Plumb. Plan Check Elec. Plan Check
- - Mech..Permlt Fee: 1AIPERAIl Plumb. Penni/ Fee: Elec. Perma Fee:
Oth71avp.
. Insp. 0.0 hrs $45.00 Ocher Plumb Insp.L—i L—] Li
Other Elco. Insp. -
Adecee: Plumb.hap. Fee.' Dec Insp. Fee:
NOTE: This estimate does not inchede fees due to other Departments (La Planning, Public Works, Fire, Sanitary Sewer Distric0 Schoe
- U15a9Ci e[C:. I neJe eeJ uro uuoca ws a^c • c.u,x..u.
FEE ITEMS (Fee Resolution 11-053 Eff' 7/1112)
... o.....»..... ... _......__
FEE
_._._ _--
QTY/FEE
_.-- ._- __-_
MISC ITEMS
Plan Check Fee:
$0.00
1 # Mechanical
$133.00 lWR=<I00 Fumace, Forced -Air
Suppl. PC Fee: Q Reg. Q OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
SuppLTnsp. Fee:Q Reg. Q OT
O,p
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$45.00
Construction Tax:.
Administrative Fee: 1ADA9N
$42.00
_ O
O
Work Without Permit? O Yes Q No
$0.00
Advanced Planning- Fee:
$0.00
Select a Non -Residential O
Building or Structure ®A
Travel Documentation Fee: ITRA VDOC
$45.00
Strong Mofion Fee: 1BSEISAHCR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
x A
$133.50
$133.00
TOT EE
$266.50
Revised: 10/01/2U12