04070118 CITY OF CUPERTINOxx""';
BUILDING DIVISION PERMIT d -OST kit.>C�QR 1\ VNY �Tjd
BuILDINGADDRESS: VALLEY HEATING & COOLING PERMIT NO,O4O7O118
OW NER'S NAME: PERMITLSEUEDATE
AL
ONE: SANITARY OL NO.
A0.CHITELT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
uO0 LICENSED CONTRACTOR'S DECLARATION Job Description
U I hereby afirm Nu 1 am Iicuumd under provisions of Chapter 9(commencing P
'Z„j .Wa S.aim?0MB IDI 'alert 3afdm Bud. fCssloN Codc.md!my license is
<N$ nmum an err a `Z�- ��o REPLACE FURNACE (7OK BTU)
S & Date Lich
n p Dem Cantrmbr
4� r IARCHITECTS DECtAR ON
77 1 ane �y PI rhan he awe pare n o
pyo ll^u AWi..
03
Licensed Pmfessir el m!
3 OWNER UmLDERptfr DEC ATION
I hereby.(Sere o n 1 am exempt from the Conuamr,License Law for the
00 which re mason.(Section
Permit
t 703 1.5,Business and Professions Cade:Any city or coumy
u�$ which royuirts r pcmit to c'exquires the Jtec improve.h Permitdonsolitt sere pair any structure
prior,its issuance,also requires the applicant for such permit m fie a signed aut)mem
=� lento racing wit purwant loth)of Divious of the ConvtcmraLimnalaw(C Code)
Sq.Ft. Floor Area Valuation
�$ (commcnc racingwithSection a and t f Division r of e&HO,xineuend Proficasion.Any
CMe)or
that he is exempt therefrom and the buts for the JIegW campdon.Any vlolauun of
Section 9031.3 by any applicant for a Permit subjects the applicant to a civil penalty of 3@&N91&h*cr00 Occupancy.Type
not more Nen Ove hundred dollar.(5500). v ,
❑I,as ower oflhe property.or my cmployces with wages as their sole compena0on,
and dothcshon,aneth The Cominotmrenanom Lawrwra pa,apply.town weer of Required Inspections
and Property
h bu Code:The Comm�ors std who Law does ret apply to an owner is q p
Own employ b,Provided
tat suces h
who are ssuchwarkhimaelfarthrtmerough base
however.the
pr loch Improvementsarene year l"ced oroQuW Onow.r.
however.Ne bve th{u improvement is sold within one year of completion,Ne owners
builder will have the human of proving that M did ret Wild or improve for purpose of
sale,).
1,as owner of the property,am exclusively convecting with licensed mourocbra to
construct the project(Sec.7044,Business and Professions Code:)The Contactor,Li.
nu law does not apply to an owner of Properly who builds,or improves thereon,and.
who cormclsformch projects with a contractor(A)licensed pursuant a the Contractors
re taw.
0 1 C
are exempt under Sec ,B&PCfor this arse/n ,
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby alllmt under penalty of perjury one of the following eedentions: -
I haus ma will meintein a Certificate of Consent to self-mum for Workers Compere ,
tetion,as provided for by Section 3700 of the labor Code,for the Performance of the
wad for which this permit is issued.
1 have and will maintain Wodct's Compensation Laurance,as mgJred by Section
3700 of On labor Code,for Ne perfomentt of On wod for which this permit is issued. -
' My Work ompena' nlnaurentt esmier see Polirynu r '
Cartier. No.
f - CER IFlCATE OF EXEMPTION FROM WORKERS'
Y/ COMPENSATION INSURANCE
(LTu sari¢mad nut bccamplewd If the permit is(orotic hundrtddoliaa(3100)
or lea.)
1 canify that in the performance of the work for which this permit is issued.I shall not
employ any person in any marteran u in become subject to the Workers Compensation
Laws of Cnifamia.Date
Applicant
NOTICE TO APPLICANT,If.after making this Ccni0cue of Exemption,you should
become subject to the Woderb Compensation provisions of Ne Labor Code,you must
.,O forthwith comply with such provisions or this permit shall M dmmed revoked.
Z� CONSTRUCTION LENDING AGENCY
^4 I hereby e1Tum that there is a connaNnn lending agency for the performmcc of
Rs'► the work for which this permit Is issued(Sec.3097,Civ.C.)
If]Q Lenders Name
6r Landers Address
U Q 1 certify that I have reed Nis application end mate that Ne shove information is
D. F correct.1 agree to comply with all city and county eminences and rete laws relating to
OU Wilding construction,and hereby audomin:repescrmives of this city to envy upon the
W maven-renimood property for inspection purposes
(Wc)agree to ave.indemnify and keep harndess the City of Cupertino against
t,i liabilities,judgments.costs and expenses which may in any way acme against aid City
U Z in consequence of the gaming of this permit.
APPLICANT UND D N WI OMPLY WITH ALL NON-POINT Issued by:9 Da
SOURCE R "% D
Re-roofs
// I
Silnuts gP can no r eta-..
4AZA1zouS MATERIALS DISCLOSURE Type of Roof
tl app lmtorfutumbuiidingmcupmistmorhandlehaarduusma24J
ranee y the Cupanma Municipal Code,Chapter 9.12,and the Hcalth and Safety
de, 0Yes 25532(a)7 / All roofs shall be inspected prior to any roofing material being installed.
❑Yes /�'tlo
Will tint applicant or Twort builtling aceupam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
not hlz Bron air momma;4.defend by the Bay Area Air Quality Management all new materials for Inspection.
Disvict?
Ycs
I have sad the hal moa muetsda requimmenu under Chapter 6.95 of the Califon
niaHcalth&Ssfcty Cod,Sc 25505.25533 and 25534.1 understand drat ifthe Wilding
does not currently he nt, r h i msponsi tility to notify the¢cup.(of the
requirements whounce of a cerdfcam orOccu me, Signature of Applicant Date
Ownc tooth r agent Date All roof coverings to be Class°$e or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
aClOF Fax(408)777-3333
$UPEI�TINO
Building Department
JOB ADDRESS: � PERMIT
OWNER'S NAME: �p PHONE #(/^ , �
GENERAL CONTRACTO FAX#
I am not using any.subcontractorsRir& ���r�C
ignature Date
Please check applicable subconta
ra tors nd complete the following information:
. SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
• Linoleum/ Wood
Glass/ Glazing
eating �S—�5—
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
er/Contraigna t Vef Date
CITY OF CUPERTINO �J
� N FURNACE/AC
cUP`ERTINO PERMIT APPLICATION FORM
APN# 76 /
/ / 1 � O/ Date: -7
Building Add r 3CJO
Owner's Name- Phone #:
7r>} ,(vlv�l w�� 4o - 87 Z- CF�iU
Contractor: License #:
G(l( 2-
Contact:
Contact: TZr(iCu U✓ Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑" Plumb ❑ Mech
Job Description: r-
1�ce �6(,-r � ftwoee
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1" floor ❑ 2"d floor ❑
• Adhere to min set back requirement(-]
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New i stall_ation Planning royal Required
Cost Prj ct Type of Construction: Occupa y u
r�
Stra ed On Platform Bonded Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qt . if
Al le 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
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
Z