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09120057 (2) CITY OF CUPERTIN O BUILDING PERMIT BUILDING ADDRESS: 941 MILLER AVE CONTRACTOR:A&H HEATING PERMIT NO:09120057 OWNER'S NAME: BUCHHOLZ,LYNN '770 CHESTNUT ST DATE ISSUED: 12/10/2009 t ER'S PHONE: 4082532499 iAN JOSE,CA 95110 PHONE NO:(408)279-0722 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB f— License Class Lic.# � ) ? 9 MECH f— RESIDENTIAL f— COMMERCIAL Contractorkk t f 9� Date 1Z I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE FURNACE&ADD A/C 220VOLT CIRCUIT (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:$6800 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:36919049.00 Occupancy Type: APPLICANT CERTIFICATION 1 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 by: Datef/2 9.18. to n Signature 1:: l /2- Jp- 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 1 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 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). 1 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. 1 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 Ow r nth ized ag e. Compensation laws of California. If,after making this certificate of exemption,1 y 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 it lify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION c. nd 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 regulations per the Cupertino Municipal Code,Section 9.18. 1 Licensed Professional (2--lo Signature L/��=""te CITY OF CUPERTINO FURNACE/AC CUPEI�TINO PERMIT APPLICATION FORM APN # 3 q&-1 1 Date: 12- -10 -09 Z _/© —© Building Address: 9�'/ W ( LLE4Z Owner's Name: Phone#: X08 Contractor: Phone#:ftp$-Z?Q-O 7 ZZ r G 1�64'� i IT�►L 1� ! j�N Fax#: YQF-2--7 - 10 Contr ctor License#: t Cupertino Business License#: 30Y C(77 Contact: Phone#: if&e-OZ?j 1157 Fax #: ` 2-7g 10f7 Building Permit Info: Elect Plumb 0/ Mech [� Residential Commercial ❑ Job Description: For Residential Installations: Attic F71I" floor [� 2"d floor 1:1 Adhere to minimum setback requirement [� For Commercial Installations: Additional weight(structural calcs) E]Replacement same weight [--] Structural Calculations required for new installation ❑ New installation Planning Approval Required ❑ Cost of Project: Type of Construction (Usage Class): Strapped On Platform ❑ Bonded New Location ❑ ReplacementK Project Size: Express ❑ Standard ❑ Large 1] Major❑ Valuation- Green Building: Please complete relevant portio rn of the Green Building Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Revised 01/07/09 CITY OF C'UPERTINO FURNACE/AC CUPEkTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group FURNACE FURN/AC 1MCRAA Commercial-Repair/Alteration/Add to M ea heating appliaice,refrigeration unit, cooling unit,absorption unit,or ea heating,cooling,absorption or evaporative cooling system,incl installation of co:itrols regulated by this code. 1MCREPALT Commercial for the repair of alt/add to M ea heating applia:ice,refrigeration unit,cooling unit,VAV boxes, absorption unit or ea heathing, cooling absorption,or evEporative cooling sys, incl install of controls regulated by this code. 1 MCSUSHTR Commercial Install/Relocate ea M suspended heatex,recessed wall htr, or floor mounted ur.it heater. 1PGASCOM Commerical for i;a gas piping System P 1-4 outlets 1BPGAS For each gas piping system of 5 or P more per outlet. 1MCAPPVNT Commercial for the install/relocate/ or M replacement of e i appliance vent installed & not incl in an appliance permit. 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICO Commercial Seismic B 1MRRAA Residential Repair/Alteration/Add to M ea heating appliance,refrigeration unit, cooling unit,absc,rption unit,or ea heating,cooling,E.bsorption or evaporative cool ng system,incl installation of controls regulated by this code. 1MRSUSHTR Residential Install/Relocate ea M suspended heater,recessed wall htr, or floor mounted unit heater. CITY OF CUPERTINO FUR74ACE/AC CUPEkTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Grou 1MRAPPVNT Residential for the install/relocate/or M replacement o.'ea appliance vent install &not incl in an appl permit. FURNACE FURN/AC 1 PGASRES Residential for ea gas piping system of P 1-4 Outlets 1BPGAS For each gas piping system of 5 or P more per outle t. 1BCBSC Cal Bldg Stan lards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Residential Seismic B 1 MECPLNCK Mechanical Plan Check M 1MFR=<100 Furnace Syst<=100k BTU install or M relocate ea forced-air/gravity type furnace/burner, incl ducts/vents attached to su;h 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/1i 1EPERMITFEE Electric Permit Fee E l 1MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Permit P c ' 1 TRAVDOC Travel Documentation B 1BUSLIC Business Licc;nse B CITY OF C UPERTINO 5L_1 FURNACEAC CUPEf�TINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Grou AIR FURN/AC CONDITIONING 1 BCAIRHAN Commercial A/C Units <= l Ok CFM B 1MCRAA Commercial Mech Repair/alt/add M 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICO Seismic Commercial B 1PGASCOM Commerical for ca gas piping System P 1-4 outlets 1PGASRES Residential for epi gas piping system P of 1-4 Outlets 1BPGAS For each gas pi,)ing system of 5 or P more per outlet. Comm/Resid 1BREMAIRHAN Residential A/C -znits <= IOk CFM B / 1 MRRAA Residential Mech Repair/alt/add M 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residen-.ial B IEPERMITFEE Electric Permit E 1MPERMITFEE Mechanical Pemlit M 1 PPERMITFEE Plumbing Permil P 1TRAVDOC Travel Documentation B 1BUSLIC Business License B AS Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 CUPEI�TINO Building Department JOB ADDRESS: _ PERMIT# !�/ r OWNER'S NAME: (3 G.Z- PHONE # -� Z GENERAL CONTRACTOR: 'req FAX # I am not using any subcontractors: S ignature Date Please check applicable subcontractors and cors plete the following information: SUBCONTRACTOR BUSI]vESS 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 Owner/Contractor Signature Date