04100184 (2) C[TY OF CUPERTINO
Bu1Ln1Nc DI VISION PERMIT ,C_0WIiXGT0RYNF0RMAT� ON �
BUILDING ADDRESS: PERMIT NO.
04100184
OWNER'S NAME: PERMIT ISSUE DATE
ONE:
SANITARY _ ..C OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
qqo �m
yU-
LICENSEDCONIRACnderp DECLARATION IO �tt_� _
1 hereby affirm Iam ONTRAunderprovisionsof ChepmrY(commencing fQCC��mm`"'
< wish Section
?IXNpor Division3 ofthe BusineessnU Profusvions Code.and my license is - - m
in full forte and effect
Lwense ClassLk.• REPLACE WALL HEATER
t'O DateContractor 4
n 1-� ARCHRECI-S DECLARATION - NOV $ 2OOI
< 1 undersand my plans shell W used as Public records
n V R tyQ{��gtryply �
3Q� License]Pmfetionel b!�_Ip ®Ip Q
g g OWNER-BUILDER DECLARATION L a�
.d i y 1 hereby,affirm tat 1 am exempt from Nc Contncmrs License Law for the N g�jl._
p 0 following Mason.(Section 7031.5,Business and Professions Code:Any city m county OOddd"'
m� which re9ui es a permit to construct,area improve,demolisA m repair any structure
,iv` Prior tea its issuance.also nquirrs lM applicant for such permit to fila a signed statement
< Our lnislicensed promemloteProviaia,aofinecnmrecbmsu<,axLaw(cltapter9 Sq. Ft. Floor Area Value on
X,0 (commencing with Section?WO)of Division J of the Business and Professions Conic)or -
E 5 9 that he u exempt Ociefrom and Nc baso for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of 3 y IMy�TeO 0 Occupancy Type '
oat marc Nan five hundred datura(SSW).
0 I,m owner of the pmpmri or my employees with wage u dnir xk mmMnudon.
will do the wort and Ne stochastic u not imcndcd or offered(arse].IS".Trot.Business
and Professions Coda:The Cion users License taw does not apply t an owner of .. _ Required Inspections
progeny who buildsorimprovex Nemon,and who docs suchwork himx]rorthrough his
own employees.provided that such improvemma are not imendcl or offered for aide.If.
however.Ne building or impmvemcm is sold within one year of completion.the owner
builds will have the Wide.of proving that he did not build m improve for purpose of
sale.).
0 I,as owner of the property,em exclusively contracting with licensed conuacmrs to
construct the project(Sec.?614,Business and Professions Codn)no Convectors Li
cense Law dos not apply m an owner of property who Wiles or improves tenon,and
who chromcts for such projects with a a...0 (,)licensed Pursuant on she Conuactors
License Law.
I sm caempt under See. B At P C for this reason - -
owner Dale
WORKERS COMPENSATION DECLARATION
1 hereby affirm under pcnahy of perjury one or tic following declarations:
I he ve and will maintain a Certificate of Camara to self-insum for Workers CumNn.
radon,as provided ear by Section J?W of to ISWr Code.for the performance of dee
work for which Nis parmit is issued.
0 I havc'and will maintain Worker's Compensation Insurance u required by Section
J?W of the Labor Cade,for the performance of the work for which this Permit is issued.
My Workers Compensation Insurance carrier and Policy number arc:
Came'. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This action need nothecomplcted if be permit is furore hundred dollars(91(X))
or Ices)
I certify Nas in Ne performamec of the work for which this permit is issued,1 shell nob
employ any Nixon in any manner an as in become subject to dm Workeri Compensation
Laws of California.Data
Applicant -
NOTICE TO APPLICANT:If.after making Nu CcribEcate of Demotion,you should - - -
become Subject to the Worker's COmocnsnion provisions of the Labor Code,you muss
.Jz roMwith comply with such pmvislons or this Permit shall W doomed minded,
Z O CONSTRUCTION LENDING AGENCY
f" Ihereby affirm that there is a comunconn lending agcnry,for the performance of
C' Ne work fur which this permit Is issued(Su.7097,Civ.C.)
CLenders Name
=z Lenders Address
. Q I certify Nat 1 have read this application and sum that the shoe[information is
L
0 U correct.1 ons tr ct comply with all city and county mdinan¢a and statet laws reining e
OU .1hovongconitmctianand forinuauthodremprexnutisrs of Niscity menmr upon tc
} aWve (Weoormil).,me
ertysaw,fmimnify an keep ha
(•^ 0. (We)egme to cast,indemnify and hick harmless the City of ru,agents against
fp judgments,of the cawing exponent which may in any way accmc against said City
U z inmmiCANT of UNDERSTANDS
SNis Permit s
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of App]icaRone
HAZARDOUS
US MATERIALS DISCLOSURE Type of Roof
Will Nc a Cupertino
or(Muni Wilding k.Chapter
store of handle Huardous material
C da.Sed Section
the Cupertino Municipal Code.CTaNmr 9.13,and Ne NcalN and Safety
Ca][,OYo.355R(a)? AN. All roofs shall be inspected prior to any roofing material being installed.
Will do applicant in future building mcupam tax equipmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air concomitants M defined by tc Bay Area Air Quality Management all new materials for inspection.
District?
[I yes ` Nu
1 have mad on haaarc ous materials nquimmcmu under Chapter 6.95 of tier Califon
ria Health&Salary Code.Sections 25515.15537 and 255214.l understand thn it tic Wilding
it.rot curtcndy bast a ten.L Nat it u my nexprnsilnlity an notify the occupant Of he
requimmenu which must tic met Prior to issuanm of a Certificate of Occupanry. Signature of Applicant Date
owner or anthmived rSent Date All roof coverings to be Class "B"or better
1
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Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS- PERMIT #D
OWNER'S NAME: //`l PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
ass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
r� CITY OF CUPERTINO
« ' FURNACE/AC
UPEi6TINO PERMIT APPLICATION FORM
WN # Date: DC'f . 2& Z
Building Address: '
Owner's Name: Phone #:
�o s e k L _ MG��r �, J - zs- -5 49 ,--4
Contractor: Phone: License#:
mow 7-ki. C/a c
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description:
vze - (a C -v- W-, ( I i
Residential ❑ Commercial ❑
For Residential Installations:
Attic ❑ 1 s` floor ❑ 2"d floor❑
dhere to min set back requirement❑
Weor Commercial Installations:
placement 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:
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
Applicable 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
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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-�e�•Y � �r��i
CITY OF CUPERTINO
a�TYOFWATER HEATERCUPINO PERMIT APPLICATION FORM
APN# 2 Z< DatbC GJ�O
Building dd1 E It-2
Own Asa L L ,, �/ �/ Phone #:Ll 0 _
C rector: f} 9R : U/ 1M /A/G of — License #: / c7
NE G � acrn
Contact: Phone: Cupertino Business License #:
BIdin Permit Info: F/1 7 / ��7 /
F �W 4C C
Bld g ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project:: / V O O
Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replacement
Qty. if
A Dlicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING