03070220 CITY OF CUPEWHNO r ✓L zs xi+ air > ss ¢ t*°a ':«�+
BUILDING DIVISIONPERMIT CONTRACTOR,INF®RMATION -i
m
BUILDING Anuaess: PERMIT N
CONDITIONED AIR I�3O7O220
OWNER'S NAME: 1701 LITTLE ORCHARD ST PERMIT ISSUE DATE
SATYA KARNALAQ7/29/2003
NE: (408) 291-2220 SANITARY NO. CONTROL NO,
ARCHITEC IENGINCER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MCCIi
0 0 0
±Op LICENSED CONTRACTOR'S DECLARATION
Ew❑ I hereby athat I am Ismosed under provisions of C plCr 9(commencing Job Description
sW with Section 9IXX))ffirmnf Division3of orcB as and Pru ssi dc,and cnscjs
in full fame and ft`-aK FURNACE & ADD A/C (3. TON) &
: = License
FINALE®
n-;o Date ant,.c.r 30AMP CIRCUIT FOR DISCONNECT,
S 8 ARCHITECT'S DECLARATION
1 understand my plans shall be used az Public means
SEP'
O
PCI 2 2003
,ow Licensed Professional
sto3 OWNER-BUILDER DECLARATION
<y 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
0 BusinessBUILDING®ING
c following reason.(section)031.5. m and Professions Code:Any city county pV L
<m fdi which sequins a Permit to construct,alter,improve,demolish,or repair any structure
dZ> prior ser its issuance.also requires the applicant for such Permit to Gln signed statement t5O6
EZO thot heisRccnsedPursminInthe provisimeoftheCommercisLicense Law(Chapmr9 Sq. Ft. Floor Area Value
e. (commencing with Section 7(M)of Division 3 of the B usiness and Prufessum;Cak)or
$ that he is ac rp,therefrom and Ibe basis for the alleged exemption.Any violation of v
Section 7031.5 by any applicant for a permit subjectsetNe applicant to a civil penalty of pEIO O
not more fiva hundred dollars(s5ro). - Occupancy Type
❑ 1,az owner of the property,or my employees with wages as their sole comprnudon,
will do the wurk,and the someone is nut intended or offered for sale(Sec.1044,Business R ��fI�ID� t
and Proonb
Professions Code:The Catm's License Law docs not apply to an owner of 303 - ROUGH N T'II�N I LtGns
property who builds of improves thereon,and who does such work himself or through his
own candayccs,provided that such improvements are not intended or offered for sale.IL 304 — ROUGH ELECTRICAL
however,the building or improvement is sold within one yew of completion.the owner.
builder will have the burden of proving that he did not Wild or improve for puryose of 505 - FINAL ELECTRICAL
s1C')' 508 - FINAL MECHANICAL
❑ 1.as owner of er Property.am exclusively contracting with licensedcnntnaors U.construct the projectpply to in ownBuser
and Professions Code:)The Contractor's nd
cense Law coca rnot suchP1ro m ts owner of progeny who builds or improves Ibemrac and.
whocontractsLacts far such pmFets with a convxmr(s)licensed pursuant m the Contractor's
License Law.
❑I am exempt under Sec. ,B&PC for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
T hereby if rm under pointy of perjury oro of the following declarations:
1 haw and will maintain a Cenificam of Consent o Self insure for Worker's Compcn-
setion,ns Provided for by Section 3700 of the labor Caen,for the performance of the
ark for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as saquitad by Section
3700 afore labor Code.for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number aa:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
or less.)(This section need not W completed if be Permit is for uoe hundred dollars IS 100)
1 card fy Nat in the performance of the work for which this Permit is issued,I glall not
employ any person in any manner so az to become subject o the Workeri Compensation
Laws of California.Dal,
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Cam violation provisions of the Labor Crete,you must
Des forthwith comply with such provisions or this Permit shall be deemed revoked.
ZN CONSTRUCTION LENDING AGENCY
I nobody a1Rrm Nal there is a construction lending agency for the performance of
3' the work for which this permit is issued(See.3041,Civ.C.)
1 0 Lender's Name
3 fandcr's Add.
J Q 1 certify that 1 have read this application and state that the above information is
1. F comely 1 agree to comply with all city and county uninan,es and Bata laws relating to
JU building construction,and hereby aathorne ripresenutiws of this city to enter upon the
X44 'hove-mentioned Property for inslenihn purposes.
Ill. (We)agree to saw,indemnify and keep harmless the City of Cupertino against
N Incoisequnce of the column of this eswhich may in anyway accroe against said City
..3Z incoithes.consequence of the granting espea Parboil.
SOURCE E U ATIO TAND A ILL CO LY W,TH ALL NON-POINTIssued by: Da
119pro n,ofA,pltea.VCmu.Id, T•'Y,[�"/�—D - Re-roofs ..
Issue
6
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building oecupant store or handle hnardous material
as deBned by the Cupertino Mark Code.Chapter 9, L end Ne Health and Safety
ak.5cc0on 35533(x)?
❑Yes No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or mor ,doming ocenpant tx equipment
or device's which
If a roof is installed without first obtaining an inspection,I agree to remove
llhman,ma air contemn as dcfncd by tbe Bay Arta Air Quality Management all new materials for inspection.
taco
❑Ycs 0 N
I have read ore W aannusmarerials requirements under Chapter 6.95 of the Califon
ria Health&S cty Code,Sccuum (15.35533 d3553d,lundcrstvW thu ifthc building
dors.1c 0y have us my n oohy mmaythe uP Ioftbe
re. vire whit be al t - f1't"LS6FAba o(Oc panty
G Signature of Applicant Date
Owner ser authorised amid All roof coverings to be Class "B" or better
aa
CITY OF CUPERTINO v3 � 7 ��� o
FURNACE/AC
OF
CUPEII;TINO PERMIT APPLICATION FORM
APN# � �. �� Date:
Building Address:
10377 G �-
Owner's Name: Phone#:
ntra�to Phone: License
2,W 5/6
/ Z,
Contact: Phone: S Cupertino Business License#:
Building Permit'Info:
Bldg ❑ Elect 3K Plumb 0. Mech
Job Description. "� �a - 7 D, Dao 6f14 C�f e
-arc Q� 3 Tars
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1"floor ❑ 2nd floor❑
• Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: Occupancy group:
X506 • C4
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
A licable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
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 BUILDING
/ EPERM[ITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
1 PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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