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05040140CITY OF COPERTINO'�'�r1- BUILDING DIVISION PERMIT CONTIiACTORAINFRORMATION BUILDING ADDRESS: PERMIT NO, ANDERSON RADIANT HEATING 05040140 OWNER'S NAM PERM17ISSUBDATE NE: SANITARY OL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDGzOMECH PLO O O LICENSED CONTRACTOR'S DECLARATION Job Description P 1 hereby affirm that I am liceamd under provisions or Chap, 9 (commencing whin Section'10(N)of D' Ision ofdm Business. "I license's infullfmwmoieff � sae.« REPLACE HYDRONIC BOILER De Cu ARCHITECT RATION 1 undcrnanJ my plena shall he umJ as Puhlic acnAs s/ Licensed Professional OWNER-BUILDER DECLARATION 1 h..A..(Sero I am exempt from the Contracmol License Law for the e Cole: Any city Of County followingmason (S.aut 1(15L;Businessand on veto dernm which requires permit In cors al,. improve, demolish, nrea repair any tdmcture n the g poor to its sensed pursuant ow statement LiccnscLaw(CMPkr9 that to the theapplicantfor mchpctor's License the Sq. FL Floor Area Valua[ o oflheegedexearud Code) or me cnnwitpurstion7 ofDivinmofthe eBussnexis (cat xemwith heefrom ndthDivisions ption. Any vi Nn he is li and the basis for Ibe alleged exemption. Any sty of 3'J��1(J`bT�er00 Occupancye 7'P it psn by any applicant fora permit objects the applicant a civil penalty of io 31.5 b any applicant Seniors not mero th.n fir<nandmdden.n (veno). noun ❑ 1, As owner Cribs, property, n my employees with wages u their sok compensation, Required Inspections will do the work, and Ne A Wcture is not inknded oroffnvd retook (Sec. 1041, Busibe.• And Profession. Code: The Contractors Liceme Law does nl apply to an owner of properly who builds orimprove. thereon, and wh.does.uCh work huromitorthrough his own emPlnycu, provided that such improvements an, not intended oroRered for sale. If. however, the Wilding or improvement is sold within ane year of (ompletion, the ownn builder will have the burden of proving that he did not Wild or Improve four purpose of ails.). ❑ 1, as owner of Ne property, am exclusively contracting with licensed contractors to construct the Projca (Sec. 7014. Business and Professions Code:) The Conommea U. _ cane Law Ones not apply to an owner of property who builds or improves Ther an, and who contracts for such projects with a cmarocam(a) licensed pursuant o the Contractors License Law. ❑ I am exempt under Sec. . B St P C for this recon Own, Dale WORKER'S COMPENSATION DECLARATION 1 hereby afNm under penalty of perjury ane of IM following declarations: 1 haw and will maintain a Certificate of Consent to self-Insure for Workers Caspian. suinn, u provided for by Section 5100 of Ne Labor Code, for the performance of the wort for which this permit is issued. ❑ 1 have and will maintain Worker's Compensation Insurane, u required by Section 31 MiM r Cod^ ev for thc Performance of the work for which this Permit is issued. dion n arad Policy nu rue: s }__Poliry Ce No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE ('Otis section need not W completed If the Permit Is for one hundred dollars (SIM) or less) I Can& On, in the performance of the work for which this permit is issued. I shall not empty any person in any manner m as to become subject to Workeri'ComPcnsation Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Ccnificnc of Emaro m, you aboard hee.me subject to the Worker's Compensation provisions or the Labor Code, you must forthwith comply with such provisions at this Nmail.hall h. dttmed revoked. COy51RUCfION LENDING AGENCY I hereby affirm pt t then is a construction lending agency for the performance of the walk for which t 6 permit Is i ued (Sec. 3091. Civ. C.) Landers Nam. lender's Add 1 certy that I have ad this application and suite that thea Wve infotmuiun is Corma.la AsComtel are all cit county ordinances and .tate laws rclatingto building nsWetion, dhemb erne representatives of this city to enter upon the above- nlioned P ray f spenionosil.porpoises. (We) ague to as , ndcmnify and tear, humless the City of Cupertino against limbi scare Ju encu sac and expenses which may in any way accmc against mid City In nmq ccof egrenting of Nis permll. Ll DERSTANDS AND WILL COMPLY WITH AL NON-POINT Issued by: Date ULATIO 5. �,(' 7 Re-roofs r Sig A It nUComractm Da, HAZARD S MRIs DISCLOS E Type of Roof Will applicant tar lure Wil ding.. wuomo andlchuallousma,rial u ine the Cnpertl Municipal Code, apkr 9.12, and the Hoolth end Safety cod , Caen 2ss5z(, . E] Yea All roofs shall be inspected prior to an roofing material being P P� Y g g installed. Win the plicant or future b occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove it havardo it contaminants fined by thc Bay Area Air Quality Management all new materials for inspection. vial ❑Ys u I ave aNrws marerials reyuiremenu under ChapsA.95oftheCalifor- nits 6 n ,Sections 255115.25555 and 25534. I understand thuifthe Wilding data t Cu ase a knent, nut It u my responihility m wtify ted rccupent of the rcq rcme v bmuslM pnortoi-"..cut. Certificate f Occupancy. Win Q S- Signature of Applicant Dale All roof coverings to be Class "B" or better wnlaraul as da to Date CITY OF CUPEkTINO CITY OF CUPERTINO PERMIT APPLICATION FORM os-bv0l�—o FAPN # 27O� Date:ilding A��D� G, Mailing Address (i different from building address): Owner's e: Phone #: ��Xi Contractor License #: 7/?-�� Con ct: Phone: Fax: gitP'c Cupertino Busi es License#: 3 Building Permit Info: Bldg ❑ Elect ❑ Plumb ❑ Mech EBS Job Description: /% QQ Residential �" Q/ld�t i/��C//�PiC �S/�ercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: , Cost of Pro; �oOO) Occupancy Group: Type of Construction: Please check this box if the project is a second -story addition: ❑ Project Size: Standard ❑ Large ❑ Major ❑ Boiler> 500K to 1M Btu 1 of 3 #,2_� �3 � $-1 -zG , '� � Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax — Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD I Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 #,2_� �3 � $-1 -zG , '� � �- CITY OF CUPERTINO CITY PERMIT APPLICATION FORM CUPEkTINO 2 of 3 Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE PbIg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit > 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non -Res A liance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/A aratus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Re air/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM • 3 of 3 Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGN& Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Planning LR Comme/ Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING • 3 of 3