04030031 (2) CITY OF CUPERTINO ay .�, y3 'Ir L (fv �
BUILDING DIVISION PERMIT 'CONTRA' ayo.;
BUILDING ADDRESS: ATLAS HEATING PERMIT NO 04030031
Ocill TARRY WV
OWNER'S NAME: PB UIESUEDATE
HAROL
NE:
SANITARY NO. CONTROL NO.
4
AR CHITECffENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
0 0 0 0
y O O LICENSED CONTRACTOR'S DECLARATION
a 1 hereby strum that 1 am Bmnxd under prevision or Chapter 9(commencing Job Description
< with Section 7000),dDivision Sof e' and Profcsaluna Codc,and mylie....
r� c ww,.ww c
in m0fom an FURNACE & A/C CUT IN F''vA LEE
y Y12 Loan
t.'.1 Date Con '
n_e
AR ITELTSD NATION N
y I understand my plans shall be used n Public mcnNe MAR 1 0 2004
3't; Liccnud Professions]
g OatIam exILDERempt
DECLARATION
Conn ON
I hcmhy olTrm that 1 em exempt from the Connector's License Lew for the BUILDING
O O following mason.(Section ND 1.5,Business and Professions Code:Any city or county
which requires a Permit W construct,slot,improve,demolish,or mpur any structure
rZN prior hs in issuance,also requires the applicant for such permit to rile a signed moment
< that he is licensed pursuant 10the prevision&Ofde,Conmelm'sLimvcLaw(Chapter 9 Sq. Ft. Floor Area Valuation
z $ (commeneing with Station 7000)of Division 3 tripe Business and Proration Coals)or
3..
that be is exempt therefrom and the hub far Ne alleged exemption.My violation of
section 7031.5 by arty applicant fa a permit subjects the applicant he a civil penalty of am N316&N2�1 MB%r0 0 OType
trot roan five hundred dollars(5500). Occupancy Y YP
❑L as owner of the property,or my employees with wages as Nair sole compensation,
will do the work and Ne awmuo is not mhori d or offered far sale(See.7044,Bnioess
and Profession Code:The Contractor's Licensee Law does not apply m an owner of Required Inspections
property who builds or(mprows thcmon,and who does such work himself or through his
own employees,provided that such improvements arc not intended or offered for sale.If,
however,to building or improvement is sold within one year of Completion,Ne most,
builder will have Ne burden of proving that he did not build or improve for purpose of
ale.).
❑1,as owner of the property,am exclusively contracting with Ransed conommn W
convect the pmject(Sec.7044,Business and Professions Code:)The Conuacors U.
corue taw does not apply to an owner of property who guilds or improves thereon,ad,
who contracts for such projects with a ornamentals)licensed pursuant to ties Contractor's
License Law.
❑I sol exempt under Seo ,B&P C for this mason
Owner Dale
WORKER'S COMPENSATION DECLARATION
l I hereby strum under penalty of perjury one of the following declaration:
I haw and will maintain a Certificate of Consent to self4nmm for Worker's Compcn.
cation,as provided for by Section 37M of the Labor Code.for the performance of the
work for which this permit is issued.
1 haw and will maintain Worker's Compensation Insurers=,as;required by Section
3700 of the labor Code,for the performance of the weak for which this permit is issued.
17
Worker's Co�mypennsadm Innsurhom�earierand olicy mberao:
Car
CERTIFICATE Of EXEMPI709 WORKERS'
COMPENSATION IN RANCE
musseclion red not M completed if the permit is foronehundreddollan(6100
or Ins)
1 certify that in the performance of the work for which this Permit is issued,I shall not
employ any person in any manner an as to become subject to the Worten'Compenati so
Laws of California.Dom
Applicata
NOTICE TO APPLICANT:IL after making this Cenificau or Exemption,you should
become subject W the Worker's Compensation previsions of Ne Labor Code,you must
,J O forthwith comply with such previsions or Nis Permit shall W deemed raaketl.
„z„ CONSTRUCTION LENDING AGENCY
Ihemhy oMm that them is a conuoolm.lmdingapenry for the pnrfurrem.or l
a> On,work for which this permit is issued(Sec.3097,Civ.C.)
Q Lenders Name
CL.z Lender's Address
U Q 1 anify that 1 have rand this application and stale that the above Warned.is
ty correct.l agree W comply with all city and county Ordinances and stale laws relining to
0 building convection,and hereby auNorina opmscnmivn of this city to enter upon the
W above-mentioned property for inspection purposes.
P. (We)agree to saw,indemnify and keep harmloss the City of Cupertino against
fn liabilities,judgments.costs and expenses which may in any my acmm against said City
U',[ in consequence of the Stenting of this Permit.
APPLICAVIF UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
rby
UL�'1 5
J Re-roofs
ApplicanUConttactor Doe
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
m applicant or forum building occupentmom or handle hevallous materiel
Ne Caperton Municipal Code,Chapter 9.13,and Ne Health and Safety
a zss3zla>7All roofs shall be inspected prior to any roofing material being installed.
s Nothe applicant r rut m building Occupant than euipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
s air canmminaats m defined by the Bay Arca Air Quality Management all new materials for inspection.
❑Yes
1 hew mad the heated nus maorolsm pormients under Chapter 6.95 of the Califor.
nia Health&Safety Code,Sections 25505.25533 and 25534,1 understand that if the building
time not cu fitly hem a t1m,that it is my responsibility W nodl'y the occupant of the
Welch, ichmus t ornoiasuanaoraccninaoof P;2&q Signature of Applicant Date
ganecrtratmttixedagem w All roof coverings to be Class"B"or better
aClOF
Community Development
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
10300 Torre Avenue
UPEkTINO
Building De artment
JOB ADDRESS: �C�S�� ,�22y w�y PERMIT # U �ZJJ
OWNER'S NAME: (ZflLD tn+-1oJ-SoAJ PHONE # e 3 /
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
Glass / Glazing
Heating T LL6 3
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
3 - �-0
er/Contractor Signature Date
1 CITY OF CUPERTINO
FURNACE /AC o q-L->3 "-
CUPEkTINO PERMIT APPLICATION FORM
APN #
6, �0Z10a"I Date:
Building Address: �3
nq
105 ( 'r
Owner's Name Ph ne#:
�•-�cu-o,L �oh�5
Contracts . License#:
IS
Contact: Phone#:
S S3
Y-) o N 13� -os► h
Applicant/Contractor• I
rd
Building Permit Info:
Bldgle t1umbech
Job Description: I
Residential: V Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation: 4�oQo-�
Type of Construction: Occupancy Group:
Qty. 'f
A Ie Fee ID Fee Description Fee Group
BENERGY Energy BUILIDNG
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 ct'm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMI'I'FEE
NA Permit Issuance MECHANICAL
PPERMITFEE Plumbin Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees __ BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG