03110048 (2) CITY OF CUPERI'INO »^d a r� � 'tr.' d;" #i� " 'a"S--�arr �
BUILDING DIVISION PERMIT CONTRACTOR INPORMATIQN
r M.
BUILDING ADDRESS: HUSSEY BROS INC PERMITN003110048
111220 PA
OWNER'S NAME: 640 TAYLOR AVE PERMIT ISSUE DATE
GEORGE JAC UIN 11/12/2003
PONE-, (408) 733-6360 SANITARY NO, CONTROL NO.
ARCHITECrIENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
ioa LICENSED CONrRACTOR'S DECLARATION
t w 1 hereby Alston that I am licensed ander provisions or chapter 9 mommmeWg lob Description
im Scctien7"),rDivision3of Ne Bu sin andP fssiore Code.mdmylicenscls
+ „ inral1.Cl n rc�Tr REPLACE FURNACE (FORCED AIR)
jq? Licenu Cl 1L. .V.._—Lick
-a„❑ Dare /
ARCHITECTS D Cun Q
D
��t A
3,3U �5.6nderstanJ my plans shall M used ss public records
e
G Licensed Profcssimmi
.O
1 ,1 OW NER-BUILDER DECLARATION
2<y I hereby affirm that 1 am exempt from the Contractor's License Law for the
p o following mason.(Section 9131,5.Business and Professions Code:Any city nr county
$ which requires a Permit to construct,almp improve,demolish,or mpair any structure $2900
aZy prior In its Issuance.also requires the applicant for such Permit to rile a signed statement
�g+m< that he is licensed pursuant o the provisions of the Conaactorh License Law(Chapter 9 Sq. Ft. Floor Area Valuation
2Fa (commencing with Section 70M)of Division 3 of the Business and Professions Code)Or 35621034 . 00
I�S that he is exempt therefrom and the basis for the alleged exemption.Any violation or
Section 7031.5 by any applicant fon permit subjects the applicant to a Civil penalty Of APN Number Occupancy Type
not mom thm five hundred dollars($50]).
P y YP
1,as owner of the pmKrty,or my employees with wages As their sole compensation.
will do me work,and the structure is not intended or offered tarsale(Sec.miq Business
and Proressimn Code:The Connacmh License law does not apply to an owner of Required Inspections
prepeny,who builds or improve thereon.AM who does such work himselfor through his
own employees,provided that such improvementsare not intended oroRemd facade It, _
however,Ne building or improvement is mid within one year ofcompletion.the owner.
builder will have the burden of proving that he did not build or improve for purpose of ✓s
sale.), t,9
I,es owner of the prepany,am exclusively contracting with licensed Convectors to
convect the project(See.7044,Business and Professions Code:)The Contractor's I
cense law dors not apply to an owner or property who Wilds or improves themon,and.
who cartnets for such projects with a conaactor(s)licensed pursuant to the Contractor's .
License I
❑I am exempt under Sec. B A P C for this Mason
Owner Data
73011WORKER'S COMPENSATION DECLARATION -
1 hereby affirm under penally of perjury,ane or the following deslaraimns:
1 have and will maintain a CeniBcom of Consent to elf-inmm rut Worker's Compcn.
M
ion,as provided for by Section 3700 of the labor Code,for me Performance of the
rk for which this permit is issued.
I have and will maintain Workeis Compensation Incur¢,ss inquired by Section
ofthe labor Cade,for the performance of me work far which this permit is issued.
Workersg nm�easatin Ins nce carrier and Policy number art:
A
S FL7 t Fyv� PaRry. LL�/1�L16U 1 a
CERTIFICATE OFEXEMPpIONOFR MWORKERS'
COMPENSATION INSURANCE .
(This metinn need not be completed tribe Permit Is intone hundred dollen 15100)
leas.)
1 certify that in the performance of the work for which this permit Is issued,I shall not
employ any person in any manner so As to become subject 0 the Workers Comirensamn .
Laws of California,Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
became subject 10 the Worker's Compensation previsions of the labor Code,you must
JQ forthwith comply with such provisions or this permit hall be deemed revoked.
r� CONSTRUCTION LENDING AGENCY
{--d I hereby affom that there is a construction lending agency for the Performance of
me work for which this permit is issued(Sea 3091,Civ.C.)
:k7 Q Undeh Name
= Z Landers Address
U O 1 cenify Net I have read this application and stain that the above information is
14 H correct,1 agree to comply with all city and county ordinances and state laws relating to
DU building convection,and hereby authorise mpresentatives of this city to enter upon the
r C shave-mentioned property for impaction putposoa
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in anyway accme against said City
U;dc
eomequcne th ranting of this Permit.
PPLICANT RSTA DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date -
OUR ERE
t
11ry 0 �z
Re-roofs
ature ofApplicanUContmccuHAZARDOUS MATERIA DISCLOSURE Type of Roof
Will me applicant or future Wilding Occupant stare or handle haismous material
fined by tM Cupenino Municipal Code.Chapter 9.13,and the Hcmh and Safety
Me,Section 355R(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yas
Will the applicant or marc building«cupam use cyvipmem ar device which If a roof is installed without first obtaining an inspection,I agree to remove
it 1112 us air commumanu d`dcnnN by the Bay Area Air Quality Mmaicmcnt all new materials for inspection.
iasict? 1/?y//�"\
Yes
I have mad the ItuvaNr usmamrials requirements under .Chapter A.95 of the Califor.
nia Healthfk Safet .Sections 25515,35533 and 25534.1 uncm land data ifthc Wilding
docs nm cunen tenant,Nat it a my responsihiluy notify t amupant cf me
requircmentatvhI pdonnissuance7:CcnifiamoI p Signature Of Applicant Date
own a,m1mrimdagcnt D, All roof coverings to be Class"B" or better
CITY OF CUPERTINO o 3 � � � � Szj-,
FURNACE,/AC
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
�( Zl 03 /I12_a�
Buildi Address: I
11 2 Lo pe d o S V tr4e s C
Owner's Name: Phone#:
Cm-eor e .7aC6tvt " Vat 2_ -;L.—b70/
Contract10 : Phone: License #:
11 uSse 13rn . Yb P 73D-4360 67 -2S-467
Contact: Phone: Cupertino Business License #:
S eve. H�55,e2j.
Building Permit Info:
Bldg ❑ Elect ❑ umli❑� Mech �=
Job Description:
MPIQ(l' �/ 'K l yrK0.i
Residential Commerc'al ❑
For Residential Installations:
Attic ❑ 1" floo2"d floor❑
• Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural talcs) ❑
Structural Calculations required for new installation ❑
New in lation Planning Approval e uired ❑
Cost ojec : Type of Construction: Occupant gro :
Strapp d/ ❑ n Platform ❑ Bonded ❑ Sq.Ft. 17190 ea:
I
New Location Replacement ❑
Qg—if
A li able Fee ID Fee Description Fee Group
ENERGY 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 Plumbin Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License Z P..ILJILDING
,4�() 9