13070126 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10697 CULBERTSON DR CONTRACTOR:CALIFORNIA DELTA PERMIT NO:13070126
MECHANICAL INC
OWNER'S NAME:
MESA,AZ 85206 PHONE NO:(866)692-5273
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIALE]
License Class Lie.# "l ADD(N)HVAC UNIT IN REAR YARD AREA(DUCTLESS
_ SYSTEM WITH EVAPORATOR UNITS INSIDE).INSTALL
Contractor Date (N)
I hereby affjr that I am licensed under the provisions of Chapter 9 220V OUTLET RECEPTACLE FOR CONDENSER
(commencing with Section 7000)of Division 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:$12000
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 APN Number:37536034.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply:with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 D LAS ALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Date
: 9115 ) 1-3
granting of this permit. Additionally,the applicant understands and will comply a y'
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
r9 any
roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as 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 HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent Date: '— �
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 CONSTRUCTION LENDING AGENCY
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 I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or.this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
GENERAL PERMIT APPLICATION �` V MER
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION /�O
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 '(1
CUPR'1`�NO (408)777-3228 FAX(408)777-3333•building
Cc�cugertino.org
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. ❑PLCIMBING�' /� MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS / / e/ APN# C� r 3 / `Z
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EMAIL
.. STREET ADD STATE,ZIT; TFAX
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CONTACT NAME II, E-MAIL
PHONE
// CITY,STATE,ZIP FAX
❑OWNER ❑,�44WNER-BUILDER.. OWNER
AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT .
CONTRACTOR NAME :- LIC NUMBER LICENS TYPE BUS.LIC# -
C� vb - 20
OMP E-MAIL FAX
S E DRES CITY,STATE,ZIP
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ARGI3ITECTIENGINEERNRME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS i CITY,STATE,ZIP PHONE
USE OFI. i-1.❑SFD of DUPLEX ❑ 'MULTI-FAMILY PROJECT IN WI.DLAND ❑ YES PROJECT IN El IS THE BLDG AN ❑.YES
BUILDINCr i ❑COMMERCIAL URBAN INTERFACE AREA JJJ ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF*61k
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AL VAt UATION �'1 O
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By!my signature low;I certify to,each of the following: I am the property owner or authorized age act on eriy o half. I have read flus
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application and t{Te information ht►ave provided:is correct. I have read the Description of Work and verify it is ac ee to co ply with all applicable local
ordinances and state laws relatmgto building co on. I authorize representativ pertinoto enter the above-i ifi perty for inspection purposes.
SlgiTature of?:p�licant/Agent� Date:
l 9
INFORMATION REQUIRED C
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' .. A EPMiscApp_2011.d6c revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10697 CULBERTSON DR DATE: 07/19/2013 REVIEWED BY: MELISSA
APN: 375'36 034 BP#: ''VALUATION: 1$12,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY PENTAMATION FURN/AC
USE: SFD or Duplex PERMIT TYPE: i
WORK ADD N HVAC UNIT IN REAR YARD AREA DUCTLESS SYSTEM WITH EVAPORATOR UNITS
SCOPE INSIDE). INSTALL (N)220V OUTLET RECEPTACLE FOR CONDENSER
MINI MENEM= - ,11 , ._
Via; C`
Mech.Plan Check 0.0 hrs $0.00 Plumb. Plan Check Elec.Plan Check 0.0 1 hrs $0.00
Mech.Permit Fee: 11vPERMIT Plramb.Pe rmii F'ee: Elec.Permit Fee: IEPERMIT
Other Mech.Insp. -1 hrs $4j
Chher Plumb Insp. Other Elea Insp. 0.0 hrs $47.00
�llech.Insp.Tee: Plumb. Insp.Fee: Elec.Insp.Tee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These fees are based on the prefindna information available and are only an estimate. Contact the Dept for addn'l info,
FEE ITEMS (Fee Resolution 11-053 E . 7ff 11112) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 1 # Mechanical
Suppl.PC Fee: 0 Reg. ® OT 0.0 hrs $0.00 $70.00 IMRRAA 7 Evap Cooling System
PME Plan Check: $0.00 1 # Mechanical
Permit Fee: $0.00 $70.00 1 1BREMAIR Heat Pump(<=10K cfm)
Suppl. Insp.Fee-.0 Reg. ® OT0,0 hrs $0.00 Electrical
PME Unit Fee:. $0.00 $47.00 IBREAMECEP Recep/Switch/Outlets
PME Permit Fee: $94.00
Construction Tax:
Administrative Fee: IADILIIN $44.00
Work Without Permit? 0 Yes (E) No $0.00 0
Advanced Planning Fee: $0.00 Select a Non-Residential (E)
Travel Documentation Fee: 1TRAVDOC $47.00 Building or Structure ®A
Strom Motion Fee: IBSEISMICR $1.20 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
$187.20 $187.00 $374.20
Revised: 07/01/2013
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SCOL U� f { CUPERTINO
c / f Build'
'Rs DQparG'rtent
JUL 19 2013
REVIEWED FOR CODE
i COMPLIANCE
C 1 Reviewed By.
rl
211 R
0FP`I
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RRe—mvp
.JUL 1 , L U i:)
COMMUNITY DEVELOPMENT DEPARTMENT \
BUILDING DIV! ION-CUPERTINO `� ��
AIS ROVED
This set of plans and spec !cations MUST be kept at the
job site during construct! n. It is unlawful to make any OT PLANS
changes or alteration on same,or to deviate CgED BX
therefrom,without appro al from the Building Official.
They s' ;n in of this DATE 1 q Z�0)3
P g is plan .d specifications
SHALL NOT
be held to per n approval of the violation
of a ovi c Ordinance or State Law, NI1VG DEPT.
DATE I DATE
DA
PERMIT NO. o:�O P Z-6
BLDG. DEPT.