04110049 (2) CITY OF CUPERTINO . ,-.�•Fars +sa, :s'""'..r�`5`A'e'^� ' , +'2x iav
: nmumrvc DLvlslory PI RMIT" 4iCIONTRAGTOR INFORMATI®N .
BUILDING ADDRESS: - PERMIT NO.
0 CONDITIONED AIR 04110049
AM XRY Wy PERMIT ISSUE DATE
_-- - ST. SANITARYjq Qj 2Q�NI'ROL NO.
ARCHITECTrIENGINEER: --.sax_ ..BUILDING PERMIT INFO --
BLDG ELECT PLUMB METH
L o o LICENSED CONTRACTOR'S DECLARATION -
w F I hmby affirm dui I am Raved�LJer proviGom of Chalner 9(commencing IobDeseription
iW wiN ] of Division]ofdx Bwofcssiuw Code.and my license is - -
^ N in full forte effm
5na a°° "' .REPLACE FURNACE & A -
m r'—aft Lie.0
nF� Dam III G /nu Crinin r ^� _ .. /C
It- / ARCHfIECTS DEC
K l,lrwMersunJ my pHw shell he used u p Ic me _
3LLp
y o Limmctl Pnrfcssirinal _ _
OWNER-BUILDER DECLARATION
<3 1 hereby. 1 am exempt from ted festoons Co License Law for the _ - -
p 0 which ng mnaoaPermit
(Section 7031.5,Business Ar ,brom on.de Professions h,or Any oily or county �G-
K m which us issu n pmmio re uiez Me alcor,improv,demolish,or repair Loy swment
tcturne cap
on,Mor itissnamc.also atto Me theapplicant for such Contra tot's icensle ae ned aw(Chtemcm
< NatheislittnWithSeumtmd¢pmviviowafMe ortheBuumrinw<�Law(CNplcr9 Sq. Ft. Floor Area alta 0
Of es (commencing with Section Division of the eusinwsand Professions _
Of
that he u exempt Nmcfrom and ted basis for IM alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subject Ne applicant rn a civil penalty of ppN N❑cob
not mare man fin hundred dollars(s5Bm. 316 0 2 0 3 6.0 0 Occ a y Type
I,as ownu of du interparty,m my amployas with wages m their wle compensation,
willdohewmlaandtheawmvte isnotimmndedorofhredfmmlc(Sa.7066,BwirCm Required Inspections
and Professions Code:The Contractors Limns.Law does Out apply to an owner of - q P
property who builds orimproves themon,and who doessuch work himself orthmugh his
own employees,provided that such improvements an,not intended aroReted formic.If. -
hmwever,me building or imprinment is sold within one your of cmmpkuon,the owner-
builder will haw ted burden or proving con tat did nos build or harrow rat puryose or
vle.).
❑1,as owner of the property,em exclusively contracting with licensed conrractom to
construct the project(Sec.71166,Business and Professions Code:)The Convector s Li.
come,law Jon not apply to an owner of property who Wilds or improves hemmn,and -
whocontracufor such propecu and,a conrracmr(s)licensed puuusnt to me Comncmh _
License law. '
❑1 an exempt under Sec. ,B h P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury ane of me following declare mu:
I ban and will maintain a Certificate ofComent Or self-iwum for Worker's Compcn- - ..
cJ lion0(nmscciipp
w provided for by Smuon 3700 of me Lather Code.for me performance of the
h his permit is issued.
will maintain Worker's Compensation Inamoce.us required by Section- -
or Cade,forthepedormanceofhewofkforwhichthispermiruisscod.
Compudadonln=man nier�ond Policy�fnumberam
fYnA\�fsv'sC Po1RstNb:'
CERTIFICA FROM WORKERS' ...
COMPENSATION INSURANCE
head nos W completed little permit is formic hundred dollars(glIXO
or lass.)
1 certify that in she performance of ted work for which his permit is issued.l shall Out
employ any person many manner so as an Mcome subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should . .
became subject to the Worker's Compensation previsions or he labor Code.you mom
.JO forthwith comply with such pravisiom or this permit shall W seamed mvoked.
Z '--' CONSTRUCTION LENDING AGENCY
F� I hereby Or.that mere iso murearcdon lending agency l'm me paffurmamx of
fY he work for which this permit is issued Sc,.304/,CO,C.)
{gl Q Lenders Name
Z I<nders Addict
V C) 1 certify hat 1 have read this application and roam this the Man information is
LL " mann.1 agree m comply with all city and county ordinances and state laws relating to /
0U building construetion.and hereby authorim mpresmwtives Of thio City to enter upon he
}W abrin-mentioned property for impaction purposes.
(We)agree to sans indemnify and keep hafmleta the City of Cupertino agaims
F'y liabilities.judgments,cost and eapemas which may in any way accrue against said City
V Z
in APPLICANT cUNDERSTANDS
of Me granting of IhrND TW ILL COMPLY WITH ALL NON-P INT Issued by: Date
s0 REGU TIO S.
2�05
1/1 0'/-' Re-roofs
Sigaatu of Appli<HAZARDOUS MATERIALS DISCLOSURE Dam Type of Roof
Will the applicant or future building occupant store or handle havardous material
as defined by the Cupertino Municipal Code.Captor 9.12,and me Health and Safety
Coda,Seaan25532(a)? All roofs shall be inspected prior to any roofing material being installed.Ely. No
Will the applicant Of future Wilding occupant use equipment or Jcvicn which If a roof is installed without first obtaining an inspection,I agree to remove.
it hamodous air contaminant as defined by the Bay Arca Air Quality Management all new materials for inspection.
ialrict?
l ❑Yes F10
1 have mal me IuraNrms materials mquirtment under Chapmr6.95 ofthe Gliror
nia Heiii &SMLyCodc,Smuom25N15.25533 and25536.1 understand!thaifth<Wilding
does,not currandy have a anent that it u my rcsprinsibility to notify the occupant of he
requirements which must Wmet pno,0 inuuuce of a certificate of Occupancy. Signature of Applicant Date
o arauthodxdagent Date All roof coverings to be Class"B" or better
Community Development
CupeIf rtino CA 9 014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
9UPERTINO
Building De artment
JOB ADDRE§54, 06q S WY PERMrr # O
LI OoLi Ci
OWNER'S N • , 0 PHIOo #
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 \
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Adak Tile
1/ 6
/Con actor Signature Date
CITY OF CUPERTINO
10,
FURNACE/AC T
CUPEkTINO PERMIT APPLICATION FORM
APN #3 Z v� Date:
ii- 9-
Building Address:
o t9 a a a-
Owner's Name: Phone#:
aeFF ` vy c25a-5D1S�
Contractor: Phone: License #:
on,4 � 5-,oe_ • 44 g-sl(Da
Cntact: Phone: Cupertino Business License#:
h,�v l Vl �f o$ -�2q a ��
Building Permit Info:
Bldg Elect Plumb , Mech
JRRb Description:
K� R 1�> on �-
Residential 91 Commercial ❑
For Residential Inst Ilations:
Attic ❑ 1" floor 2"d floor❑
Adhere to min set back requirement LK
For Commercial Installations:
Replacement same weight Ig- Additional weight(structural calcs) ❑
Structural Calculations required for-new installation ❑
New installation Planning Approval Re wired ❑
Costof,Project: jIypeofConstruction: Occupancy cup
Strap� d Ki— . On P tfdma X Bonded ❑ Sq.Ft. Floor Are' :
New Location ❑ Replacement
Qty. if
A ligable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIl2HAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
1 EPERMITFEE Elec Permit Issuance ELECTRICAL
7 MPERMITFEE Mech Permit Issuance MECHANICAL j
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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