04040153 CITY OF CUPE12'1'INOM -
BUILDING DIVISION P11 RMIT �'.;CONTRACT QRANFORMATION.
BUILDING ADDRESS: SCHAUMANN AIR CONDITIONING PEBMTN%4040153
RY DR
OWNER'S NAME: PERMIT ISSUE DATE
WEN TSUI n4 /23 /2004
ONE: SANITARY NO. CONTROL NO.
(408) 428-0640
ARCHITECfIENGINEER: BUILDING PERMITINIeO
BLDG ELECT PLUMB MECH
0 0 0 0
�Op
LICENSED COanned ad,, DECLARATION FU NBAp sem®
la F 1 hcrcby affirm thm I am Ifthe BJ under provisions of Chapter 9 fammause is Job Description u� 1 [tl�o
=W with Section]gXgnf Division]of the Business and Prufcssions Code,and my license is
n tour cand�If Tl REPLACE FURNACE & ADD A/C
psa2 Manx Clea Lit.p -
;_w Data Contractors MAY 10' 2004
ARCIIITECrS DECLARATION
a I understand my plans shall M.,oil as public records
Ta O Licensed PctxnaloBUILDING UIL®IUN
3 OWNER-BUILDER DECLARATION
Nva y 1 hereby of firm that I am exempt from the Contractor's License law for the
00 following reason.(Section 7011.5.Business and Professions Conde:Any city or county
<w ff which requires a permit to construct,alter,improv,,demolish,or repair any structure
L=} pno(1r11tS 1SS.anCC.a1,Wr[q.Ife2lAe applxanl for such(ICrm111a hleai i'mad Statement
=EQ that he is licensed pursuant(it the provisions ofthe Contractor's Livers,Law(Chapter 9 Sq. Ft. Floor Area Valuation
yF (cnmmencing with Section?Wh of Division]or the Buslocse and Professions Code)(it
i;$ that he is exempt therefrom and fee basis for the alleged exemption.Any violation mf
Section 7011.5 by any applicant for a Permit subjects the applicant 10 a civil penalty of 3 6902Q13 crO 0 Occupancy Type
m
nut ore than five hundred dollars n.50o). P Y YP
❑h as owner of the property,of my employees with wages as inch xle compensation.
will do the work,and the swclure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor:License Law it.not apply to as owner of Required Inspections
property who builds or improves thereon,and who das.such work himself or through his
ren employees,provided that such improvements Smoot intended oroRcred for sale.If.
however,the building or improvement is sold within one year of completion.One owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
I,as owner of the property,am exclusively contracting with licensed convectors to
nstnct the project(Sec.7044,Business and Professions Code:)The Contractor's Li .
ccosc Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law.
0 l am exempt under Sec. .B h P C for this..an
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of Perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self-insum for Wuron'sCumpcn-
sation,u provided for by Section J]00 of the Labor Code,for Ne performance of the
work for which this permit is issued.
1 have and will maintain Wurkcri Compensation Insurance,as required by Section
371W of the"her Code,for the performance of the work for which this permit is issue].
My Workers1Cconforms tinn lnsun('cc carticr and Policy number am _
CrunnosdG �}n Policy No.: 11`I3� Z_
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
min xetioo recd not he complced if de permit is forum,hundred dollars(SH30)
to ICSS.)
1 artily that in the performance or the work for which this permit is issued.I shall not
employ any poem in any manner set M le become subject to the Workers Compensation
Laws of Cal i forms.On
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the lahnr Cole,you mum
.JO forthwith comply with such provisions or this Permit Shall In deemed revoked.
Z " CONSTRUCTION LENDING AGENCY
t--i I hereby affront that Nitre is a construction lending agency for the Performance of
the work for which this permit is issued(Sec.1097,Civ.C.)
U.1 Q under',Name
= Z Lender's Address
U 0 1 verify that 1 have read this application and some that the above information is
ty ^F bonen,l agree to comply with all city and county ordinances and stag laws relating to
DLe above mentioned m,Bndherebywthonprposesentativesof NisCity tocmcrupon the
r CL above (Weia agree
property for inspection an keep ha.
(We)reg tic to save,indemnify and keep harmless the way accuse
us Cupertino against
Esq in
equnce of ei.the cosgracing expenses which may in any wayaceme againstsaid City L
J ineonxganee of the granting of this Permit. f'
/lam
APPLIC UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: - Date
SOU E GUL ONS. J
z y/03/064 Re-roofs
Signature or ApplicamoCon haul4or Data ----/��
HAZARD613rNfATERIALS DISCLOSURE Type of Roof
Will N,applicant or future building occupant store or handle hanNuus material
u defined by the Cugeninn Municipal Cade.Chapter 9.13.and the Health and Safety
Calc,Section 3551](4)? All roofs shall be inspected prior to an roofing material beim Installed.
So
rare ❑Nu P P Y g g
Will the applicant or future building Occupant use cquipmem or nevicas which If a roof is installed without first obtaining an inspection,I agree to remove
it ha'rardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
istricl?
❑Yes ON. - sl/n(may)//"
Ihavc read thehaaallouns 25505.2553als and255341coacrea u Chaper 695 if the Wilding J1.'— /
ria Hwlth ASafery Cexle,Sections 8NI5,35511 and355J4,IunJerstand that if the Wilding
stns nm currently bm,a)e�nt one II is my re,,poembility to mei IY the oacua nt of the
require ,n which mul m h,IpnmmissuancaoraCcNBeaeof17ce pancy Signature of Applicant Date
Owneror authorizcJ aFe 2 Data All rocf cov rings to be Class"B" or better
Community Development
y✓� 10300 Torre Avenue
fo Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPERTINO
Building De artment
JOB g6S S r / IT #
Gr'/- - OK0DIs3
OWNER'S N
GENERAL CONTRACT% <42P&"fna,9n i 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 u C
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile ''
ZS/ C4�
11 Off{}Conture ate
CITY OF CUPERTINO
("rat�- FURNACE /ACCITY Of
CUPERTINO PERMIT APPLICATION FORM
APN# p 2 03 Date:
a3lb
Building Address:
Owner' Name: Phone#:
toev-) "- u `l 4l0-359
Contractor: License#:
Conta • Phone#:
I 'Q ��c2 0 - y23- o
Applicant/Contractor:
Building Permit Info:
Bldg Elect Plumb Mech
Job Description: ' 2 4c c C»
Residential: JC Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valu
Type of Construction: �7 Occupancy Gr up
Qty:if
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
EPERMTTFEE Elec Permit Issuance ELECTRICAL
1 MPERMTTFEE Mech Permit Issuance MECHANICAL
PPERMTTFEE --flumbing Permit Issue PLUMBING
BPERMFEE Bld Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
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