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10110041 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21578 ROSARIO AVE CONTRACTOR:VALLEY HEATING& PERMIT NO: 10110041 COOLING 0- 'ER'S NAME: MARSHALL WILLIAM J AND ELIZABE 1171 N 4 TH ST DATE ISSUED: 11/08/2010 OWNER'S PHONE: 4082557574 SAN JOSE,CA 95112 PHONE NO:(408)294-6290 ❑ LICENSED CONTRACTOR'S DECLARATION r (— BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# 46 r- F / /I _ MECH RESIDENTIAL COMMERCIAL Contractor VQ f�l C��'Firg L Cly,li ep Date �l/�� 0(© I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:FURNACE REPLACEMENT IN 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:$3574 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. APN Number:35619019.00 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 constriction,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 by: �—fG' "" Date: 9.18. Si- 'ire /z����� �/t fe l 2a'D RE-ROOFS: ❑ 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: I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work,and the stricture 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 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. I 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 Health&Safety Code,Sections 25505,25533,and 25534. 1 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 Owner or auth rzed ager / Compensation laws of California. If,after making this certificate of exemption,I �iDate:C 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 affinn 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 1 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 U, re above mentioned property for inspection purposes.(We)agree to save ir. lify and keep harmless the City of Cupertino against liabilities,judgments, costs,and 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 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: (5-7 $' Ro Sar' o AveA&ce PERMIT# v OWNER'S NAME: Li C PHONE# 40 9g--25S-7S GENERAL CONTRACTOR: Heat-!`14. C&1,';,, BUSINESS LICENSE# 1 ADDRESS: &;;tj jj, 4-: CITY/ZIPCODE: .-,n*Our municipal 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 SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum/Wood Glass/Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35619019 .00 DATE ISSUED. . . . . . . : 11/08/2010 RECEIPT #. . . . . . . . . : BS000011935 REFERENCE ID # . . . : 10110041 SITE ADDRESS . . . . . : 21578 ROSARIO AVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : MARSHALL WILLIAM J AND ELIZABE ADDRESS . . . . . . . . . . : 21578 ROSARIO AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4757 RECEIVED FROM . . . . : VALLEY HEATING & CO CONTRACTOR . . . . . . . : ATKINSON, THOMAS LIC # 141 COMPANY . . . . . . . . . . : VALLEY HEATING & COOLING ADDRESS . . . . . . . . . . : 1171 N 4 TH ST CITY/STATE/ZIP . . . : SAN JOSE, CA 95112 TELEPHONE . . . . . . . . : (408) 294-6290 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 3, 574 . 00 1 . 00 0 .00 1. 00 0. 00 1BSEISMICR VALUATION 3, 574 . 00 0 .50 0 .00 0.50 0 . 00 1MFR=<100 UNITS 1. 00 126 . 00 0 .00 126. 00 0 . 00 1MPERMITFE FLAT RATE 1 . 00 42 . 00 0 .00 42 . 00 0 . 00 1TRAVDOC FLAT RATE 1. 00 42 . 00 0 .00 42 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 211.50 0.00 211.50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 211 .50 #21250 --------------- TOTAL RECEIPT 211.50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS:,,'/5 2, (777 DATE: REVIEWED BY: APN: BP#: *VALUATION: 1$3,574 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Du01 lex 1, 1 'i. PENTAMATION FURN/AC USE: p � ��� , � ,. PERMIT TYPE: WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Furnace, Forced-Air 1MFR=<100 1 # $126 TOTALS: $126.00 Mech.Plan Check 0.0 hrs $0.00 f' 1' „' t,.�< f zr�<`'4_�<'c Mech.Permit Fee: IMPERMIT Ff,t Other Mech.Insp. 0.0 hrs $42.00 t,l t?,: ��,, 1rer ic_to��y. NOTE: Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'1 info, FEE ITEMS(Fee Resolution 09-051 a. 7,-1.10) FEE QTY/FEE MISC ITEMS supp/. PC,f'e'e PME Plan Check: $0.00 Permit f'ec: sl/pld. 111,fJ FCC PME Unit Fee: $126.00 PME Permit Fee: $42.00 f{C 1ISlic(tl 1&-vie l Work Without Permit? 0 Yes E) No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Std.s Commission Fee: IBCBSC $1.00 SUBTOTALS: $211.50 $0.00 TOTAL FEE-.T $211.50 Revised: 10/17/2010 CITY OF CITY OF CUPERTINO 11-31 FURNACE/AC CUPERTINO PERMIT APPLICATION FORM APN# --I /L,} /� Date: !r/l/<O Building Address: 5 n �( tleez"e OS4r'i o Owner's Name: l`11-4 rs �/ Phone#: 1t08'-255- �� -71f L�� �4 Contractor: Phone#: K 0 T-2+q G 2 4 0 1�Qlley kec& �t�c COO�r'2 Fax#: �24 7 Contractor License#: Cupertino Business License#: - 2 58'5 d Iff ( Contact: Phone#: 'toy--241f 2.4a Fax#: Building Permit Info: Elect❑ Plumb ❑ Mech Residential Commercial ❑ Job Description: Frcrn4G e �eerf �a 1V���0-� For Residential Installations: Attic ❑ 1st floor 2nd 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 Construc ion(Usage Class): Strapped ❑ On Platform ❑ Bonded New Location ❑ Replacement Project Size: Express ❑ Standard ❑ Large ❑ Major❑ Valuation: 3 5 7 u _ 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