05050099 77
CITY OF CUPERTINO - `
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
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BUILDINGADDRESS: ARS MECHANICAL PERMIT No 05050099
5,5,4 140T.T.&NDERRY P1
OW NER'S NAME: PERMIT LSSUE DATE _
ONE: SANITARY O. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uo0 LICENSED CONTRACTOR'S DECLARATION
C I threby alto.that 1 am licensed under prmoWms of Chapmo 9 mourmmiming Job Description
b with Section7000)eBof ecDivison3af the Business and Profcctlum Cock.and my liccnu is 1�� ���®
N mmanCI nderrent 50070 REPLACE FURNACE & ADD A/C NF
D„a{? Liccnsc Clus L Canty 7
Dam /Tr/_T=centra ter /}A/ MOVE FURNACE TO ATTIC
ARCHITECTS DECLARATION
�i I understand my plans shall x used as public menods
;may Licensed Pmfcssional
2005
` S OWNER-BUILDER DECLARATION
1 hereby affirm moi 1 am exempt from the Contractoh License Law for the
p o following reason.(Section 7031.5,Business and Professions Code:Any city or county
X m which requires a permit to construct,ager,improve,demolish,or repair any structure
m�'^ prior to its issuance.also requi,ecmc applicant forsuch permitto rile asigoedsumment
<
that he is licensed pum the e pmvism.of the Chairman's Limmon Low(Chapter 9 Sq.Ft. Floor Area al a
m_m (commencing with Section]000)of Division Sof the Business and Profcui . OO
i 3
that he u exempt dominant it the huffs far Be,alleged eaempdon.Any=of
Sectim.7031.5byasry applicamfor a permit subjects am appl¢anuo a civil penally of APN Number Occupancy Type
not more
than Rw hundred dollars(5500).
0 1,u owner of the property,or my cmplaycu with wages as their sale compensation, 36229011 . 00
will des the work and the structure is not intended or offered fo...1.(Ser.7044,Business
and Professions code:The Contractor&Live law doer not apply In an owner of Required Inspections
property who builds or improvss therenn,andwho doessuch work himself orthrough his
own cmplaycu,provided that such improvements sce not intended or offered for We.If.
however.ere building or improvement is sold within one year of completion,the owner-
builder will have she burden of praying chat x did not build or improve for impose of
sale.).
0 I.as owner of the property,am exclusively contracting with licensed contractors W
construct the project(Sec.7044,Business and Professions Cade:)The Conu reux's Li.
more law docs not apply to an owner of propeny who builds or improver therean.and
who contracts for such projects wit a eonuactor(s)licemad pursm t to the Conuactofs
License law.
0 1 am exempt under Sec. .B h P C for this season
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of dm following declarations:
I have and will maintain a Certificate of Consent to self-insure for WOrkersCo.pen-
7C37W
imn,u provided for by Section 37W of ere Labor Code,for the performance of the
rk for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
of the labor Code,for the perfaomance of ae work for which this permit is issued.
y Worker's CampemminQuinscribe.came,and Policy numbcram:n r. Policy No.;QGs 2�ap
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mossection need not Mcompleted if the Marra is fare=hundred dollars(SIM)
or less.)
I cenifv that in ere performance of the work for which this permit is issued,I shall not
employ any season In any manner W a1 W become subject to on Wnfker3 DO.pKmadoa
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:IL after making this Cenifieam of Exemption,you should
become subject an she worker's Compensation provisions of the labor Code,you most
.JO foMwuh cmally with such ponin
visu or this faumit shall x deemed.vmked. .,
Z" CONSTRUCTION LENDING AGENCY
[-rte Iharmy aMo.that chert is a construction Leading far the pctfur.ana of
a ac work for which this permit Is issued(Ser.309?,Civ.C.)
(a7 Q Lender's Nam.
0. Lender:Address
U 0 1 verily that I have read this application and sum that the above information is
ty corer.I agree W comply with all city and county onlinarms and sum laws minting to
0U building construction,and hereby W00117e teprcaenutiscs of this city to enter upon ere
,res above-arena mal property for inspection purposes.
(WO)agree to save,indemnify and keep harmless the City of Cupertino against
rTIT Iiabilities,judgmcnts,costs and expenses which may in any way accme against W City
of he
U z ranting at'his pennit,
APPLle NTCUNDERIAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR RESTANDSGULATIO
Re-roofs
Signa erre of APPlicanUCon ter Dam
HM DO MATERIALS DISCLOSURE Type of Roof
Will dm applicant err a um building Occupant nore or handle harardous material
as defined by ere Cupertino Municipal Code.Chapter 9.12,and ere Health and Safety
Cale.Scction 15532(a)? All roofs shall be inspected prior to any roofing material being installed.
0y. a
Will the applicant or future Wilding occupant use equipment or devices which if a roof is installed without first obtaining an inspection,I agree to remove
mit harsrdnus air contaminants as derined by the Bay Area Air Quality Mamgemem all new materials for inspection.
District?
CYcs (&NO
1 have real ere hvaNsWs materials rtquiromcnts under Chapter 69Sofdm Glifor-
nuHealth6SafctyCocmSmuobs Yr5,25533and2S5M.1uMersund chazifthe Wilding
does mmol,has[a tenant.ant it u m nsibdbhy m naify the occupant or of the
recto nth whim.calx I 0...(.ccnificamof Ove an Signature of Applicant Date
OS/ All roof coverings to be Class "B"or better
Ow or acomixcl agent Dam
• r Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS: PERMIT #
M /-le� 6w PZ- 05 Of6o Y
OWNER'S NAME: gi2 74 PHONE # PDQ 2,kT —
GENERAL CONTRACTOR: s X71 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
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/ ntr for Signature Date
CITY OF CUPERTINO
51-11 FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN # � / Z � o � Date:
Building Address:
gvtt"b PL
Owner's Name: Phone#
Contractor: License#:
A-U k77FCcGRAfI64L 757llG7l�
Contact: Cupertino Business License #:
6uArr,44-►J W0J(q
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ,
Job Description:
02EYU�W (G) PUfA09CE )peP6h-C.E ;!5- 1916 U•vi WIZ- IWI(/,64C 7
Residential Commercial ❑ /�
For Residential Installations:
Attic 151 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 installation Planning Approval Required ❑
Cost of Project: Type of Construction: Occupancy group:
f, 7**
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BRENIACOVER A/C Unit > 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfn 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
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