10010168 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10213 MILLER AVE CONTRACTOR:VALLEY HEATING& PERMIT NO: 10010168
COOLING
"NER'S NAME: BOB SHERRY&STEPHEN THOMAS 1171 N 4 TH ST DATE ISSUED:01/28/2010
OWNER'S PHONE: 4082036286 SAN JOSE,CA 95112 PHONE NO:(408)294-6290
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
_; y I—
MECH RESIDENTIAL COMMERCIAL
Contractor Date F` j!�
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE FURNACE,ADD A/C**SEE NOTES**
(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:$6709
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
APN Number:36914020.00 Occupancy Type:
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 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 r r
non-point souegulatio sper the Cupertino Municipal Code,Section Issued by;,--- Date: j
9.18.
op
-natur Date 1" 1d
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:
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)
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
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. 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 t ed agent:
Compensation laws of California. If,after making this certificate of exemption,I Date:
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. V7 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
n the above mentioned property for inspection purposes.(We)agree to save
,mnify 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
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 ulati s pe e Cupertino Municipal Code,Section
9.18. . Licensed Professional
Signature Date
f
CITY OF CUPERTINO
8 ITEMS OF 22 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36914020 . 00
DATE ISSUED. . . . . . . : 01/28/2010
RECEIPT #. . . . . . . . . : BS000009643
REFERENCE ID # . . . : 10010168
SITE ADDRESS 10213 MILLER AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA
OWNER BOB SHERRY & STEPHEN THOMAS
ADDRESS 10213 MILLER AVE
CITY/STATE/ZIP CUPERTINO CA, CA 95014
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 61709 . 00 1. 00 0 .00 1 . 00 0 . 00
1BREMAIRHA NO.UNITS 1. 00 63 . 00 0 .00 63 . 00 0 . 00
1BSEISMICR VALUATION 61709. 00 0 . 70 0 . 00 0 . 70 0 . 00
lEPERMITFE FLAT RATE 1. 00 42 . 00 0 . 00 42 . 00 0 . 00
1MPERMITFE FLAT RATE 1.00 42 . 00 0 . 00 42 . 00 0 . 00
1MRRAA UNITS 1.00 63 . 00 0 . 00 63 . 00 0 . 00
1PPERMITFE 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 295 . 70 0 . 00 295 . 70 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
---------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
t
r CITY OF CUPERTINO
FURNACE/AC
`M OFPLICATION FORM
Cl�PE1�TiN0 PERMIT AP
APN# Date:
C-� (,0C
Building Address:
c� 12) �ey- vt,
Owner's Name: Phone #:
4160
Contractor: Phone#: 4
Fax#:
Contractor license#: Cupertino Business License#:
e_�!5�z
Contact: Phone#: LIDS
Fax#:
Building Permit Info:
Elect PlumbEl Mech
Residential Commercial ❑.
Job Description:
For Re idential Installations:
Attic ❑ 1St floor [ 2nd floor 1:1
Adhere to minimum setback requirement L
For Commercial Installations:
Replacemcnt same weight ❑ Additional weigrit (Str't�Cttir ai calcS) 71
Structural Calculations required for new installation ❑
New installation Planning Approval Required El
Cost of Project: Type of Construction (Usage Class):
v
Strapped ❑ On Platform El Bonded New Location Pr Replacement
Valuation:
Green Building: Must attach Green Building Check list to this application
CITY OF CUPERTINO
FURNACE/AC
CUFF OF FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
FURNACE FURN/AC
-1PGASRE-S Residential-of r ea gas piping systein of-- P -- --
1-4 Outlets
IBPGAS For each gas piping system of 5 or P
more per outlet.
1 B SEISMICR Residential Seismic B
1 MECPLNCK Mechanical Plan Check M
1MFR=<100 Furnace Syst<=100k BTU install or M
relocate ea forced-air/gravity typef '
fumace/burner, incl ducts/vents L�
attached to such appliance up to and
include 100,000 Btu/h
1MFRN>100 Furnace Syst> 100k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance over
100,000 Btu/h
1 EPERMITFEE Electric Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
1PPERMITFEE Plumbing Permit P
1
r 1 TRAVDOC Travel Documentation B
1BUSLIC Business License B
CITY OF CUPERTINO
FURNACE/AC
P T
�U R�1NO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
AIR FURN/AC
CONDITIONING
IBCAIRHAN Commercial A/C Units<= 1 O CFM B
1MCRAA Commercial Mech Repair/alt/add M
1BSEISMIC0 Seismic Commercial B
1PGASCOM Commerical for ea gas piping System P
1-4 outlets
1PGASRES Residential for ea gas piping system P
of 1-4 Outlets
1BPGAS For each gas piping system of 5 or P
more per outlet. Comm/Resid
1BRE Residential A/C units <= 1 O CFM B
1 Residential Mech Repair/alt/add M
1BSEISMICR Seismic Residential B
1 EPERMITFEE Electric Permit E
1MPERMITFEE Mechanical Permit M
1PPERMITFEE Plumbing Permit P
1 TRAVDOC Travel Documentation B
1BUSLIC Business License B
- 1 U
CD U
0 0
❑ Enter description here,and enter points available for measure in appropriate categories to the right -_ -_ — -----.-------_--_---_-�-• 0
�- Enter description here,and enter points available for measure in appropriatL categories to the right __,___.___.._ _—.__-
❑ _Enter description here,and enter points available for measure in appropriate categories to the right __ _ __ —y _ _____.______ 0 D - _ D` 0_— _-
❑ Enter description here,and enter points available for measure in appropriate cateoories to the right 0— -0 0 D D
Build It Green Chec0ists and
4.Innovation:List innovative measures that meet the green building objectives of the Guidelines.Enter up to a ` uidelines
maximum combined total of 20 pts.See Innovation Checklist for suggested measures,using the link to the eight. ____i_ _^— —
Innovation in Community:Enter description here,and enter points available for-measure in appropriate categories to the right 0 D _0 -_�—D- 0 0
❑ Innovation in Energy:Enter description here,and enter points available for measure in appropriate categories to the right. 0 D
o points available for measure in appropriate categories to the right. D 0 - D _ D_ __0.— 0
❑ Innovation in lAQ/Health:Enter description here, enter p a `
❑ Innovation in Resources:Enter description here,and enter points available for measure in appropriate categories to the right D - 0 D 0 0 _ -0 _
o r 'n ro nate Categories to the ri hi _ D D 0 _�-0 D D
❑ Innovation in Water.Enter description here,and enter points available for measu e i app p g 9 ___.-_
-- Total Avallable-Points in-Other=43 0
Total Available Points in Specific Categories` 4+ 196+ , 42+ 166+ 143+
Minimum Points Required in Specific Categories 0 30 6 J 6 I 9
7ect has not yet met the following recommended minimum requiirements: , f`
-Total Project Score of At Least 50 Points
-Required measures: �j r
-A3a: 50% i4laste diversion by weight ( _
-JZ-X15°:o-abo��e—Title-24
-td1:Incorporate GreenPoint Rated Checkdist into blueprints
-Minimum points in specific categories:
-Energy(30 points)
-1A01Health(5 points)
-Resources(6 points)
-Vater(9 points)
02007 Build It Green Single Family GreenPoint Checklist 2D07 Version Page 4 of 4
K Community Development
f>. 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF
Fax(408)777-3333
7UPEkTINO
Building Depart ent
JOB ADDRESS: PERMIT #
Z Lo XA 1; Z 06/9 lt,�l-7
OWNER'S NAME: PHONE # Agety 2�D
GENERAL CONTRA TOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractos an complete the following information:
F- -a SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
ne zctor Signature Date