06010132 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRA.C�TOR INFORMATION ";
BUILDING ADDRESS: PERMITN0.0 6 01013 2
22069 WALLACE DR
OWNER'S NAME: PERMITISSUEDATE
PARCEL JAN 01/24/2006
NE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
X00 LICENSED CONTRACTOR'S DECLARATION O O O
C 1 hereby affirm That 1 am li¢mcd under previsions of Chapter 9(commencing Job Description T�D
b
with Section 70(IU)af Division]of Ne Business and Profcesium Code.and my is t(u l}i�y Il:.t.I yt
s L License C, and st.—r REPLACE FURNACE I�'J�J't'Jf` �i�fjtJ,`S,u ttY"1'2'(L5�/)
Ll Z
Liccn¢C �— Costa
F Dare - Cant
E ARCHITECTS D
W U undcrwnd my phos shall W used az public rtcords m 9- 2006
say Licensed Pmfasienal �+,�
3 OWNER-BUILDER DECLARATIONf�, (�,r/�a
aI 1 hereby affirm Nn 1 am exempt frum the Comment's License Law for the tgI11lJ(gLLr ttfh'I(ll tru,1\T\eY�,,p'{fit.]``
ZOO following moon. etch s 7031.5.Business and r mfessium Cede:My city or county t
e m which m9uirrs a permit m construct.eller,impmvc,demolish,m repair any xtrvcturc
$_4100
y¢i prior toils issuance.xlsumquires the 3PPlic2ntfor such permit to file a signed statement
x
< that hcislittnsedpursuant WmeProvisions ofthe Contractor's Liccruse aw(CRapnr9 Sq. Ft. Floor Area Valuation
YI-D
that
(commencingwi theraioareand)of bail forn 3 oeallegBusiness and tion.inns Code)or
y Nat he a eacmpt thcmlrom and the baso for the alleged cacmption.Any violation of
Section 7031.5 by airy applicant for a permit subjects the applicant in a civil penalty of
not more Nan five hundred della.(SSW), r Occupancy Type
❑1.Jet owner of the progeny,or my employers to wag..that sols compensation,
will do the weak,and the swcnte is not intended aroffered Tamale(Sec.7044,Business
and Professions Cade:The Commetors License law dors not apply to an owner of Required Inspections
property who builds or improves Hereon,and who docs such work himself err through his
own employees,provided that such improvements arc not intended or offered for sale.If,
however,the building or improvement is said within one yea of completion,the owner.
Wilder will have the burden of praying that he did not Wild or improve for purpose of
sale.).
❑1,as owner of the property am exclusively contracting with licensed contractors to
conswct Ne pmject(Sec.7014,Business and Professions Code)The Conracnri Li-
cense taw does not apply in in owner of pmpwy who Wilds or improves threes.and
who contmste for such projects with a contractor(&)licensed pursuatn an the Contractor's
License law.
❑I am eacmpt under Sec. ,B A P C for this meson
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby aRrm under pevlty of p do,oro of tW fallowing decladwio.:
I hive and will maintain a Cenifcate ofConscnuoself-insure for Worker'sCompen-
saion,u provided for by Section 37M of the IaWr Code.far do performance of 0a
work for which this permit is issued.
❑1 have and will maintain Warker's Compensation insurance.as required by Section
371M of the to Wr Coda,for the perforrearcc of the warts for which this permit is issued.
C.WarY,rs's C rasa' Insurance aarticr and Policy number am:/
C.
EX Policy FROM
CERTIFICATECOMPENSATION
SATION7INN FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not W completed if the permit is(mane hundred dollar(SI W)
or less)
I certify that in the performance of the work for which this permit is issued.l shall not
employ any person in any mannersou or become subject in the Wofhc Compmnation
laws o(Cahromia.Date -
Applicant
NOTICE TO APPLICANT:If.after making this Ccnificate or Esemptian,you should
become subject n the Worma a Compensation provisions of the labor Code.you moa
J z dMwith comply with such provisions or this permiuhall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[-+ 1 hereby affirm WE dome is a cunsaucdan lending agency for the performmtic of
IL' the work for which this pewit is issued(ser.3097,Civ.C.)
[7] Landers Name
= z Lender's Adelman;
U C) 1 cenify that I have mad this application and sun that the above information is -
py t-+ cower I at n comply with all city and county ordinances and state laws mining be
C)U Wilding mostnsction,and hereby suthodae representatives or this city n enter upon the
ahovc-m nudged Property for inspection
„pm en puritawhich m:.
F a (We)agree to siva,indemnify and keep hamlets 0a City or Cupenino against
h in
of thetmstsandof this camit. may in any wayaccrue against said City
U z A APPLICANT
of the RSTAgoonfing S A permit.
APPLICANT UNDERSTANDS AND WIL COMPLY WITH ALL NON-PpINr Issued by: Date — Z e7
SO REGULATIO / /
�a ( 4)6 Re-roofs
Stgnawrc of ApphcanUContraztor T—D
HAZARDOUS MATERIALS DISCLOSURE / Type of Roof
Will the applicant or Town Wilding occupant stone or handle hanrduus material
az dOrZd by the Cupertino Municipal Code.Chapter 9.11,and the Hestia and Safety,
. 0YO, _5532(a>7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
If a roof is installed without first obtaining inspection,I agree to remove
Will the applicant or(more Wilding Occupant use equipment or devices which g an p
In hanrdnua air conmmmants.d recd by the Bay Arca Air Quality Management - all new materials for inspection.
mist?
❑secs
I have road therdo.manias requirements under Chapnf6.95efthe Califon
7dms.o9LWmnt1y
Health 6 Safcty hre,Sansom 255)5.25533 and 25534.1 understand thmifthc Wilding
have a tenam,thin it is my r.ponsmility n notify occupantter Ne
achenlswhichWi melpriornieseanereracwr�anor upaney. Signature ofApplicant Dale
wner orauthori.mag t / ,n All roof coverings to be Class "B”or better
Community Development
� 10300 Torre Avenue
i�x/ Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: O �v G 0 2-�b� PERMIT#
,C.�
OWNER'S NAME: PQJl PHONE-# -& o $ 3
GENERAL CONTRACTOR: PT Zo Heart- Qom"r FAX # ( ' -73:� -c>L 119
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
Tile
Y/4
(-' er/C niractor Signature Date
CITY OF CUPERTINO
SO
SFURNACE /AC O
CITY OF I D132
CUPERTINO PERMIT APPLICATION FORM
APN # ,6�(D — (DR
_O2 Date: i c)(,
Building Address: a � J
r
Owner's Name: . X33 - c��
Phone#:
Contract S ,r License#:
O
Contact: Phone#:
a
Applicant/Contractor:
Building Permit Info:
Bldg Ele lumb Mech
Job Description:
Residential: r Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Archi tecUEngineer: Valuation:
• Type of Construction: Occupanc Group:
l� N
Qty. if
A licable Fee ID Fee Description Fee Group
BENERGY Energy BUILIDNG
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 BUILIDNG
EPERMITFEE Etec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUIL IDNG
BUSLIC Business License BUILIDNG
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