04030198 r CITY OF CUPERTINO 77' + '�,,� �,:r.77
BUILDING DIVISION PERMIT CONTRACCCC1t,INFyORMATION
BUILDINGADDRESS: TERRY BROWN PERMITND.04030198
OWNER'S NAME: PERMIT L4UHDATE
TERRY
ONE: SANITARY iP 1 OL NO.
ARCHITECTMNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
'TOG LICENSED CONTRACTOR'S DECLARATION
I bemby&ROM that I am licensed under provisions of Chapter 9(commencing Job Description
with Section 7")of Division 3OfU¢Business and Profcssiru Code,AN my licevm is
Nfull ea andeRecL WALL HEATER REPLACEMENT
5'�z
Dan_T'S MACMI
DELL
ARCHITECTS DECLARATION
I understand my ptsv shall he used As public rtcnms
3 tial Licensed Professional
OWNER-BUILDER DECLARATION
F.0 I hereby.I CC Net 11. exemptfroms An the ConuanCo e:A nae taw for the
F.O O following lemon. t 7(01.5.Business end tie, amok Code:Any city I CountyImmune
9 which iuu u a Permitm emmruct,alma.Improve,dcmoltsh,or repair any s m mre
t• i^ tum m its issuance,ala nquims tic applicant for such permit ro ee a a�Laed mammem
(comm islicensed pursuant
ecdon7 tabs ofProvisions sion(the Canniness And
Preelaw(Chaptm9 Sq.Ft. Floor Area Valuatio
,SC (commas Meneri(h SeNrns rood cal Divielon3 of the Business andon.Any
Caleof
a$ Net he is exempt Urrtfrom aM the buts for Ne allc{cd exemption.Any viol'an of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of 3_%TF"1`1a1r*gr0 0 Occupancy'l)pe
not¢ort Nan five hundred dollar($500).
❑t.as owner of the Portnoy,C,my employ=with wages u them sole mmpewUon,
will do the wort,and(heauunure is not intended Atalfernd for ask(Sec.7044,Sudnua Required Inspections
and Professions Code:The Contracmra License Law docs not apply m an came of 9 P
property who builds or improve themon,and who does such worichimsel f w demugh his
ownemployw.provided that such improvements art not imerWN moRertd forsal&if.
however,the building or improvement is sold within ON year of cnmPlolon,the maur-
builder .will have the burden of proving No he did not build or Improve for purpose of
u1e.).
❑1,AS Owner of use properly,am ucludvely contracting with licensed canuanors m 1
construct the.pm)en(Sec.7014.Budnw and Professions Cade) bREr'7D,"
cense law dots no(apply m an owner of property who builds Or Ire Csia IheMonn.Licenseacts fm such pokna wiNarnnuanor(i)licertsed pursuant the Canvxt .
who cm law. 6
1 Data 2
e der Sea B&
�'S OMPEOMPE S�ATIO
1 hereby of res under penalty Of perjury ane of the following declsoadnu:
I love and will maintain a CcmOcae of Covent to ml6ivum fer WohcbCompen-
utlon,u provided for by Section 3700 of Ne labor Code.for Ne Performance of the
work for which this permit k issued.
❑1 haw:and will maintain Workers Compensation luuoadee,u required by Section
3700rf the labor Code,for the performenocof e,work fuwhich this permit is Issued.
My Workers Compeuadrn Insurance carrier and Policy number art:
Carder, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Gyre I.need nmbecomPleled If tic Permit is forov hundred dollars(3100)
or kit.)
1 Certify that in N (romance of Ne work for which Nis permit ts issued,I Shall not
employanypcomn Br env m ob co pf AmNe Workers'CampeuNon
Laws of Celifomla
Nimcm
NOTICE P A :If.efmr aking this Conificam of Exemption.your should
become tub t m Nt Worker's Compensation provisions of Ne labor Code,you mum
.,O (orNwi amply with ach provision or this permit be dcemW revoked.
Z► CONSTRUCTION LENDING AGENCY
[ti I hereby from that Nem lit emmuNon ending ,my fordo performance of
PL> the work for which this Permit Is Issued(Sec.3M.Civ.C.)
W� Lenders Name
az Lenders Addres
U Q 1 Comfy Nat 1 have read this application and sue the the above Information is
COMM 1 agree to comply with all city and county omiduncea and man hw m(adng In
Wilding construction,and hereby authooas mpmmnwives of Nis city to enter uPnn tht
W above-mendoncd proPcrry for inspection purpose6
(We)agree m save,indemnify and keep harmless the City of Cupeniw against
W (iabili0es.judgments,com andeapeun which may in any way amus against said City
U 7 in consequence of the gaming of this Permit. h
G APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N PO NT Issued by: Date
SOURC ULATIONS
� �� ,ALi2:UL� Re-roofs
WourKlApplicafitr0ohlractor am
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ce applicant or(owe building aeupmt mom m handle buudous mamoal
As defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Amiace,Seedo
Yesn 2533i(a)? \, All roofs shall be inspected prior to any roofing material being installed.
❑ DFNu
Will the applicant Or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
in mit m7amcm air contaminants u unlined by the Bay Area Air Quality Management all new materials for inspection.
DiurictT v
❑Yes (171Nu
Ibave reW the Wamous mueoalsmquimmenu unucrCNpler6.95 Clubs Calif¢.
ria HcalNh Safety Code.Sections 25505.25533 and 25534.1 understand thatifte Wilding
does not currently hoc a mnanL t it u my responsibility to nodl'y the occupant of Ne
myvire here rrmivaancenfaCeninesearoccapurey. Signature of Applicant Date
.giffner or amhorlvnd agent 'Ons 3 m All roof coverings to be Class nBn or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CI OF Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRE oZ/'Z? G H /V:: PERMIT # O v ' Oj 6
OWNER'S NAME. �/V PHONE # o 0
GENERAL CONTRACTOR: 1A FAX # (9 -- o
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
Owne�Signature Date
CITY OF CUPERTINO
FURNACE/AC 6 �' 03 r p�
OUPERTINO PERMIT APPLICATION FORM
APN # Date:
357 - I-7 -113 3- 1 O -
Building Address:
I -7 2- c, J C',
Owner's Name: Phone#:
I E2 yLo ad & ? f -
Contractor: Phone: License #:
S-�•-� 3526 ( Z
Contact: Phone: Cupertino Business License#:
Building Permit Info: /
Bldg ❑ Eleqt5o t Plumb ❑ Mech L7
Job Description:
Residential 25 Commal ❑
For Residential Installations:
Attic ❑ I" floor ❑ 2nd floor❑
Ajhkdhere to min set back requirement❑
Ivor Commercial Installations:
Replacement same weight ❑ Additional weight (structuralEl calcs)
Structural Calculations required for new installation El
New installation Planning Approval Required ❑
Cos roje O Type of Cons n: Occupancy r—
Stra ped ❑ On Platform Bonded Sq.Ft. Floor Area:
Ne, Location ❑ Replacement ❑
Qty. it;
-APPca 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
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
NIPERMTTFEE Mech Permit Issuance MECHANICAL
PPERMTTFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business Licens BUILDING