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10110039 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21175 LAURETTA DR CONTRACTOR:BOGNER'S ALL AIR INC PERMIT NO: 10110039 OWNER'S NAME: PAYNE ZEE A AND DAVID H 5310C SCOTTS VALLEY DR DATE ISSUED: 11/08/2010 l! ;R'S PHONE: 4085698181 SCOTTS VALLEY,CA 95066 PHONE NO:(831)438-5254 ❑ LICENSED CONTRACTOR'S DECLARATION �] c� BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class o Li,-# 6 z,^- y & f I— (� MECH RESIDENTIAL COMMERCIAL Contractor/- 01t A'f/,f lq/L q/k . Date l U t I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:CHANGE FURNACE SAME LOCATION (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. Sq.Ft Floor Area: Valuation:$4470 1 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. APN Number:32655018.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. 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 Issued � � ? Date:11--,e 9.18. Signature Date v RE-ROOFS: CJ OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's ner o a th ed agent: Compensation laws of California. If,after making this certificate of exemption,I Date: A 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. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save ind ;fy and keep harmless the City of Cupertino against liabilities,judgments, cc A expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date CITY OF CUPERTINO FEE ESTIMATOR-BUILRING DIVISION ADDRESS: 7 r` {�� AT �� REVIEWED BY: APN: BP#: *VALUATION: 1$4,470 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY is !i. PENTAMATION FURN/AC USE: SFD or Duplex r i 00?"" PERMIT TYPE: WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Furnace, Forced-Air 1MFR=<100 1 # $126 TOTALS: $126.00 _T Mech.Plan Check0.0 hrs $0.00 1' f, T! ' -��L;� Fmech.Permit Fee: IMPERMIT 1"r_,,r F"," Other Mech.Insp. 0.0 hrs '_142.00] drA"h hR 1J. NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn 7 info. FEE ITEMS (Fee Resolution 09-051 E,ff. 7.'"1:-10) FEE QTY/FEE MISC ITEMS Phin ('Iieck Fc c< F-T SiIppl. PC VCC PME Plan Check: $0.00 Perini!Fcr Sr ppi'. hop Fcc> PME Unit Fee: $126.00 PME Permit Fee: $42.00 Consfrlwtion 7'ax c:��rt_stit:rr}Rcvie Work Without Permit? 0 Yes G No $0.00 Plr.rnrtirr,�.> F`cri's. Travel Documentation Fee: ITRA VDOC $42.00 A Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $211.50 $0.00 TOTAL FEE: F $211.50 Revised: 10/17/2010 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: PERMIT# / �-'// v U- !-7 A OWNER'S NAME: 19,4 el ivy= PHONE# 03 J�� `l�G, GENERAL CONTRACTOR: A/& JMC BUSINESS LICENSE# 7 ADDRESS:5310 aet CITY/ZIPCODE,,/C�r L *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCO TRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: / Signature Date Please check applicable subcontrac or and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum/ Wood Glass/Glazing v Heating �h wC. 7 / ,:74- Insulation a2Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date t CITY OF CITY OF CUPERTINO its FURNACE/AC CUPER"1INO PERMIT APPLICATION FORM APN # Date: Building Address: 2 I l 7S �1✓L'� r'^ Owner's Name: Phone #: Contractor: Phone #: Z� l�'C�ft✓YL-�S l� D� �a °C, Fax #: >3( - 4�3E, - C-:E��� Contractor License #: Cupertino Business License #: 12 06'L5 Contact: Phone #: S.1'QJI✓ G��'�1 Fax #: Building Permit Info: Elect © / Plumb Mech Residential \EZ Commercial ❑ Job Description: G N�''s Cit✓ T�::11 F0 NCS �iQ!�'� L U n4 7l o J For Residential Installations: Attic ❑ 1St floor 2"d floor ❑ Adhere to minimum setback requirement ❑ For Commercial Installations: Replacement same weight ❑ Additional weight (structural calcs) ❑ Structural Calculations required for new installation ❑ New installation Planning Approval Required ❑ Cost of Project: Type of Construction (Usage Class): 1 44-7 0 vc Strapped ❑ On Platform Bonded ❑ New Location ❑ Replacement Project Size: Express ❑ Standards Large ❑ Major ❑ Valuation: Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Revised 01/07/09