15090143 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10261 RANCHO PL CONTRACTOR:AAA FURNACE&AIR PERMIT NO: 15090143
CONDITIONING
OWNER'S NAME: SHIH ALAN S AND GU ELA ET AL 1712 STONE AVE DATE ISSUED:09/22/2015
OWNER'S PHONE: 4082238181 SAN JOSE,CA 95125 PHONE NO:(408)2934717
Od LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
REMOVE AND REPLACE FURNACE.
License Class fej Lic.#
Co tractor l.0 Date Z o r
I hereby affirm that 1 am licensed under the provisionof Chap er 9
(Commencing with Section 70011)of Division 3 of the B sincss&Professions
Code and that my license is in full force and effect. Sq.Ft Floor Area: Valuation:$1270
1 hereby affirm under penalty of perjury one of the following two declarations:
t. 1 have and will maintain a certificate of consent to self-insure for Worker's APN Number:35703016.00 Occupancy Type:
Compensation,as provided for by Section 3700 of the Labor Code,for the
erformance of the work for which this permit is issued.
ave and will maintain Worker's Compensation Insurance,as provided for by
Ar Section 3700 of the Labor Code,for the performance of the work for which this PERMIT EXPIRES IF WORK IS NOT STARTED
permit is issued. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
APPLICANT CERTIFICATION 180 DAYS FROM LAST CALLED INSPECTION.
I certify that 1 have read this application and state that the above information is
correct.1 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 Issued by: Date:
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
grant' is it. Additionally,the applicant understands and will comply with RE-ROOFS:
on-point source gulatio s p Cupertino Municipal Co ,Secti 9.18. 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
Signature ate Zia t inspection.
Signature of Applicant: Date:
❑ OWNER-BUILDER DECLARATION ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I licreby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons:
t. I,as owner of the property,or my employees with wages as their sole HAZARDOUS MATERIALS DISCLOSURE
compensation,will do the work,and the structure is not intended or offered for I have read the hazardous materials requirements under Chapter 6.95 of the
sale(Sec.7044,Business&Professions Code) California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
2. 1,as owner of the property,am exclusively contracting with licensed contractors to compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
construct the project(Sec.7044,Business&Professions Code). Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should 1 use equipment or devices which emit hazardous air
hereby affirm under penalty of perjury one of the following three declarations: contaminants as defined by the Bay Area Air Quality Management District I will
t. 1 have and will maintain a Certificate of Consent to self-insure for Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation,as provided for by Section 3700 of the Labor Code,for the I Ic &Safe Codc �"'
.Sections 25505,25533,and 25534.
performance of the work for which this permit is issued. Owner r a nt: 1*6L j2. 1 have and will maintain Worker's Compensation Insurance,as provided or by Date: I
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. CONSTRUCTION LENDING AGENCY
3. 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 I hereby affirm that there is a construction lending agency for the performance of work's
Compensation laws of California. If,after making this certificate of exemption,I for which this permit is issued(Sec.3097,Civ C.)
become subject to the Worker's Compensation provisions of the Labor Code,1 Lender's Name
must forthwith comply with such provisions or this permit shall be deemed Lender's Address
revoked.
ARCIIITECT'S DECLARATION
APPLICANT CERTIFICATION I understand my plans shall be used as public records.
I certify that 1 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 Licensed Professional
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
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 9.18.
Signature Date
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
• 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 M
I
(408) 77,'-3228 • FAX(408)777-3333•buiidina(Mcupertino.org ���l Y� S C
CUPERTINO
❑PLUMBING MECHANICAL DELECTRICAL FMISCELLANEOUS
PROJECT ADDRESS 10 ' ^ I �to/ I n `,t `7 APN 0 n�j 7-
OWNERNAME W � iI �r IVB' I PHONE itCb Zy�I l/E-MAIL
_
/ (it
J lJ
STREET ADDRESS "� I I - CITY/ T�TE [P I u SO 4- F
I I
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE, ZIP FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER
❑ TENANT
CONTRACTOR NAMEI i r \ LICENSE NUMBERI n LICENSE TYP BUS.LIC H ' C
COMPANY NAME v / I E-MAIL FAX
STREET ADDRESS( / O \ I CITY,STATE,ZIP J ��I PHONE
AR CHITECT,ENGINEER NAME v LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
• USE OFSFD.,DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT AI ❑YES IS THE BLDG AN ❑ 1-ES
BUILDING. ❑COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE EICHI.ER HOMES El NO
DESCRIPTION OF WORK
TOTAL VALUATION: IJ 70 RECEIVED BY:
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating t 7puddipgpriStruction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: 21
UPPLE MENTAL INFORI,4ATION REQUIRED OFFICE USE ONLY
w OVER-THE-COUNTER
a
F- ❑ EXPRESS
:L
❑ STANDARD
i
❑ LARGE
❑
MAJOR
MEPMiscApp_201 1.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
RPERMITTYPE:
DDRESS: 10261 Rancho PL DATE: 09/22/2015 REVIEWED BY: Sean
PN: BP#: 'VALUATION: $1,270
Mechanical Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: PERMIT TYPE.
WORK Remove and replace furnace.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $143
TOT,%LS: $143.00
Mech.Plan Check0.0 hrs $0.00
Mech.Permit Fee: IMPERMIT
Other Mech.Insp. 0.0 hrs $48.00 Other 1'111all'
NOTE: This estimate does not include fees due to other Departments(i.e. Planning,Public Works, Fire,Sanitary Sewer District,School
District,etc.). Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS(Fee Resolution 11-053 Eff 7 1 13) FEE QTY/FEE MISC ITEMS
1'rrl,/,/. PC Fc,c,
PME Plan Check: $0.00
l'c'rutil if"
.S upl/. ho
i
PME Unit Fee: $143.00
PME Permit Fee: $48.00
i
'11,N11,110ion [ax.
Administrative Fee: IADMIN $45.00
Work Without Permit? 0 Yes (j) No $0.00
!,holocvd P1,r1u,irg Fc c'
Travel Documentation Fee: ITRA VDOC $48.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
BldgStds Commission Fee: IBCBSC $1.00
SUBTOTALS: $285.50 $0.00 TOTAL FEE-.T $285.50
Revised: 07/02/2015
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