03100104 CITY OF CUPERTINO
BUILDING DhVI970N PERMIT CONTRACTORINFO��RMATIQN
Bu1LD1h��RE;s: A & H HEATING PERMITNo03100104
ER'S NAME: 770 CHESTNUT .ST PERMIT ISSUE DATE
Pm RTT
E: SANITARY N0. CONTROL NO.
(408) 279-0722
ARCHITECTIENGINBER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�00 LICENSED CONTRACTOR'S DECLARATION Job Description
1 1 hereby e(Orm that am licensed under provisions of Chador Y(commencing
with ScI her (Division I )ofdue Business pistons of hale r 9(commenci I.in fullfortco fol— ZC7 Ei, c(' REPLACE FURNACE
o n z License CI Lk. -
J Dow flanlrae
I
ARCHITECTS DEC ON 2n7
i I tend my plana shall m used as he records
dV
'0 Licensed Pnrfcssional
sp Oat I am exempt
from
m Ce Conti ON
10 0 1 hcrcby. firm that l 1. .usin from Ne Canuaam;License Law for(be
.p0 followwhich
gnresapacedoa 917L5,Bvsltasamprvs,and dcrinns Code:Any city orcounty
3$ which inquires a permit re cnniwcL alar,impmw,h permit t or A a sig ed scnmoe
:Zt that heor is
iensedprsantto 0.provisthe asofant for such permit to Law(Chapter
schapters
< (comm itcing licensed pursuant m the pro visions nr the Co usines'sni Pretensions
(C Code)
Sq. Ft. Floor Area VdlUBtlOn
1�0 (commencing with Seniors](g0)afDivision 7nf the Business and Profasiom CsxlcJ er
$ (hat he Is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 703).5 by any applicant for a acmd objects the applicant to a civil penalty of APN Number Occupancy Type
not mart Nen Eve hundred dollars($500).
Q I,an owner of the property,or my employee with wages as their sole compnsalmn,
will do me work.and the structure is not intended or offend ra,age(Sac.700,1,Busioeus 301 - ROUGH L� p CIIOHS
and Prefonahms Code:The Contractors License Law docs not apply to an owner of L
property who builds or improve&theraon,and who does such work himselforthmugh his 303 - ROUGH ME'CHANI AL
own employees.pmvidcd met such Improvements at not intended oroffered intrinsic.If, 304 — ROUGH ELECTRICAL
however,me building or improvement is said within oro year of completion,the owner-
builder will have me burden of proving dust he did non build or improve for purpose of 505 - FINAL ELECTRICAL
mak.).
O I.m mune,of the property.am exclusively emu sting with locoed contractors 10 507 - FINAL PLUMBING
convect the probe,(Sec.7oe,1,Business and pnrenian,Code:)The contraemr;Li. 508 - FINAL MECHANICAL
cease taw dean not apply to an mmer of property who builds or improve(hemon,and
who contracts for such pmjccu with s contractor(s)licensed pennant to the Contractors
License Law.
I am exempt under See. ,B&PC for this reason
Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of me following skdantioas:
I have and will maintain a CcNfiate of Continuo ulGinsure for Worker;Compn-
na0on,as provided for by Section 7700 of the labor Code,for the performance or the
work for which this permit I.issued.
01 have and will maintain Wmkcr;Compensation Insurance,is required by Soctim
3700 of due Labor Cade.for the perfarmance of lite work for which this permit is issued.
MyWorkers Compnsalio.Insurance nrtic�nn[p,PolicyV7 ,711
/u'm,M� :
CA,f.a'1'IZi.(CIC. 101%5 . 7olicy V �i, 120
CERTIFICATE 0FEX PTI0N FIR 0M WORKERS'
COMPENSATION INSURANCE
(This section road not W completed Him prmit is foram handrail dollars($100)
or las.)
I cenify the,in the Nrrommuce of me work for which this permit is issued,I shall not
employ any Nation in any manner an as in became subjeuo the Workers'Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT.If.after making this Certificate ar Esemp(ion,you should
became subject to the Worker's Compensation provitions or the tabor Code,you most
7� forthwith comply with such provisines or this pi shall be deemed invoked. -
r iCONSTRUCTION LENDING AGENCY
I W nby affirm that men its construcllnn lending agency for the Performance of
3i due work for which this permit is Anneal(Sec.3097,Co.C.) .
Y0 Lender's Name
z
Leaders Address
J Q I certify that I have read this epplicetion end scale dual me above information i&
H correct,l agree to comply with all city and county ordinances and since lam reading to
�U building construction.and hereby authorise representatives of this city to enter upon the v
„a ahove-mentioned propny for impection purposes
(We)agree to save,Indemnify and keep harmless the City or Cupertino against
TA liabilities,judgments,costs and expense,which may in any way accrue against mid City
j Z In consequence of the groat!AS of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
0 CEREGULATIG
Re-roofs
Signuurc of App i�nofApp ion Con(nctor Data ( c
HAZARDOUS MATERIALS DISCLOSURE Type of Roof t
Will the applicant or futurebuilding occupant more at handle ham utrus material
d by the Cupertino Municipal Code,Chapter 9.12,and me Health ad Safety
Section 25532(.)+ All roofs shall be inspected prior to any roofing material being installed.
[3 Y. lIIir-
Will the applicant per future building amupant on equipment per devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hoeNnm oI, Mir-
7""
As,darned by me Be,Arca Air Quality Management all new materials for inspection.
DbebCl7 '
❑Yes LsOr
I have mad the WIAMousmate ials requirements under Chapler 6.95 orthe Califon
nixHealth&Ssfc(yCodc,Secdom253()5.25533ad25534.Iun&c mdtholfthc Wilding
doe&no( creamy haw a levant,that it is my resansihillly to notify dm necupa(or due
anNiremc mm mustIm at pd ai nanaor,cm 'nea¢arCe cy. Signature of Applicant Date
net or athorived agent ,� All roof coverings to be Class"B"or better
t r .
IT
CITY OF CUPERTINO
`Y` FURNACE /AC
UPERTINO , PERMIT APPLICATION FORM Q 3���0
APN # 3 Cq 22 0 53 Date:
r Building Address:,
75$� Bou.rry GEl2 . .
Owner's Name: k)e u NPhones q3 Y9
a 3-
Contractordq� ` I License #3o IfY 7X
+; Contact: TT II Phone #:
DA•c.E PitE L.PS 74-07,RX
'Applicant/Contractor: ^ '✓
s r til Ca /TA20 7
Building Permit Info:
`
Bldg Elect Plumb ech
Job Description:
^, Residential: G�. FC Commercial:
;v
Sq.Ft. Floor Area: $/SC,Ft.:
•Y
Aei a '
`'.. Architect/Engineer: Valuation:
ype of Construction: Occupancy Group: /
l
>' Qty .
i + AppVcale Fee ID Fee Description Fee Group
BENERGY Ener BUILIDNG
BREMFURN Relocation of Furnace MECHANICAL
" - BREMACOVER A/C Unit > 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL.
BSEISMICRE Seismic Fee Res BUILIDNG
JI
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEEPlumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
• BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
l.