04030207 CITY OF CUPERTINO • ' "� �'" rx��` •'�
BUILDING DIVISION PERMIT WCONTRAC-TORANFsORMATION
BUI LDING ADDRESS: z PERMIT NO.
AAA FURNACE & AIR CONDITIO ING 04030207 '
OWNER'S NAME: PERMIT MUEDATE
NE: SANITARY OL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
e00 LICENSED CONTRACTOR'S DECLARATION Job Description
x.5 C 1 krtby affirm that I am licensed u������nder,,,,,,ppppppmvivonx^f Chapter 9(commencing
SZto wiNSec ] )of Division3ofu, Buu�gkgNO Professions Code.and mylicense is
morall forte a //`` N�Jf
�q? ea.. , �L Lia.If REPLACE FURNACE & A/C
G°^'f APR 0 5 2004
W A CHRECI-5 RATION
�y W 7U I undcrwnd my plans shall he usul as public ecnrod y pq
is Lkcnsed Prufcssimal BUILDING
Baa
OWNER-BUILDER DECLARATION eemm LDING
po1 hereby gram that 1 am exempt from the Contrivers License Law for the
K.2follnwingamon.(Seedun]Iq Ls,Business and Professions Cale:Anycisy or county
which requit a permit u)conswct,alcor,improve,demolish.or repair any structure
a;w prior p its issuance.also rrquires the applicant fm such permiuo file a signed statement
��< Nat he is licensed paruant to the,provision of the Confaclor's Limnsc law(Chapter9 Sq.Ft.Floor Area Valua[I
(commencing with Section 7")of Division 5 of da Business and Prolessitns Case)of
i $ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of 3 0 Occupancy Type
.or more titan five hundred dollars(SSW).
1,a owner of the propcay,or my employees with wages u Weir sole compensation,
will do the work,and the structure is not intended ar offered far sale(Sm.7014,Business
and Protimions Code:The Can..,',License Law does not apply so an dater of Required Inspections
pmpeny who builds or impows dtercon,and who does such work himsalf or Through his
own employ=.provided that such improvements arc nointeMW oroRved for We.If.
however,the building or improvement is sold within rote year of completion,the owner.
builder will haw de batmen of proving that M did not Wild or Improve for purpose or
ealea.
❑1,as owner of the proper,am exclusively contracting with licensed contractors to
massrov the project(Sec.7066,Business and Professions Code:)The Conrmeter's Li.
cane Law docs not apply to an owner of property who builds or improves demon,and
who concocts for such projects with a contracmr(s)limmed pursuant to de Contractors
License law.
❑I am exempt under sec. .B&P C for Nis reason
Owner Dat
WORKER'S COMPENSATION DECLARATION
I hemby alifm under penalty of pvjury oe of Ne following decluuions:
(have and will forbynoCe.37Mcaus of 0,Laonsent bor
far Wafkcr'aComp0.
work on-as providedhhi for ni Section 3]00 of We labor Code,for the performance of Ne
wort for which this permit is issued.
1 have and will maintain Workers Compensation bnurmce,as requited by Section
W of the labor Code.for the performance of the work for which this permit is issued.
My Workers Cnm s tin lnsortnce carrier and Polity numberare
rtiera e RTI OF EI(EMP"." O WORKERS'
COMPENSATION 1 URANCE
o'histoodo t need not be completed irthe Permit is form=hundred dollars(slip)
or loss)
1 cenify Wat in We performance of the work for which this permit is issued,I shall not
employ any person in any manner an as;an become wacv to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If..Mr making this Cenificam of Exemption,you should
become subject to the Worker's Compensation provisions of the Latour Code,you most
.JO forUwim comply with such provisions or this Permit shall M dccmcd ewkcd.
'Z� CONSTRUCTION LENDING AGENCY
F-p Iheehy affirm Lou there is a cunstooinn lending agency[or the Performance of
ry'7 the work for which Nis Permit is ismed(Sec.IDB],Civ.C.)
W Under's Name
M Z Condo's Add.
U0 I certify that I haw mad this application and state that the amw information is
it, E coma I agree 10 comply with ill city and county oninu mces and state laws relating to `\
pbuilding construction,and herby authome mpresemfiw of this city to enter upon the
r W .hove-mentioned property for impccuon purposes.
(, G (We)agree to saw,indemnify and keep harmless the City of Cupertino against
N liabilities,judgments,costs and expenses which may in any way accrue against said City
C.)z APPL^IIC9AN'T UNDERSTANDS AtND WILL COMPLY WITH ALL NON-POINT e of die granting of ths permit Issued by: Date 12-
15
SOU EREGULATIONS.
1Y10 V Re-roofs It
mart of ApplicanVConvamo Dae
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or hand szardom material
u defined by she Cupenino Municipal Code.Chapter 9.L2.and the Health and Safety
Colo.Scetiam lsslz(a)] All roofs shall be inspected prior to any roofing material being installed.
El yes y�No
Will the applicant or For..building me....I tic cyuipmen,or detritus which If a roof is installed without first obtaining an inspection,I agree to remove
t harafdous air conaminann as defined by the Bay Area Air Quality Management all new materials for inspection.
D strict L!
0Ycs Byrvu
1 have road the haramtms materials requirements under Chapter&95 or the Cali for.
naIlth&Safety Code,Sectiad 25505.25533 and 25536.1 underund Thu iftic building
tdnot currently hate a mars.that it is my responsibility to notify the compant of the
rcgai mcmtswnmhmustbcmctpar urissuarccofaccrdficamofComputer Signature of Applicant Date
ver or authorised agent Dae All roof coverings to be Class "B" or better
Community Development
411 10300 Torre Avenue
..:%r
Cupertino CA 95014
Telephone(408) 777-3228
CIN OF Fax(408)777-3333
�IJPEkTINO
®®
Building Department
JOB ADDRESS: PERMIT#
3 E p �ed ,30 a�6p
OWNER'S NAME: 4T a/ PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating X14.4C —
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
�M/Contractor Signature Date
CITY OF CUPERTINO
FURNACE/AC v "� �� 07
CUPEkTINO PERMIT APPLICATION FORM
APN # 2/i - 2� - Date:
(p ✓ d3-z -o
Building Address:
ue
Owner's Name: Phone #:
os-
Contractor: Phone: License #:
O C L AIC y0 -d - 7/ /lofP%
Contact: ' Phone: Cupertino Business License #:
o yo
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ILR
Job Description:
L' /u
Residentia Commercial ❑
For Residential Installations:
Attic ❑ 1" floor ❑ 2"d floor❑
iAdhere to min set back re uircment[] .
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural talcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Ap2roval Required ❑
Cost of Project: Type of Construction: Occupancy group:
G oO9,Qo
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacerne411
Qtt if
A "hcable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cfim MECHANICAL
BREMAIl21-1AN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MP
ERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING