03090191z
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CI'T'Y OF CUPER'1'INOx
BUILDING DIVISION PERMITC0NTRACTORIINE
RMATION ;.
S's
BUILDING ADDRESS:
PERMIT NOO 3 0 9 0 19 1
OWNER'S NAME:
rAqA TIE AN7A HOA
PERMIT MUE DATE
09/24/2003
NE:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELELT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensee anger provisions of chapter v (commencing
Job Description
with SceL 70 B of Division 3 oldie Bu/�siG�nfeac and Professions Code, and my license is
in fall °° f `'
Bc.N
REPLACE FURNACE & A/C
Data c
ARCHI7LLTSp RATION
CONTRACTOR: PACIFIC NORTHSTAR MECH.
I crstand my plans shall the used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5. Business and Professiotu Code: Any city or county
which mquiro a permit to enrtstruct. alter. imprnve. demolish, or repair any structure
prior to its issuance, also ¢quires the applicant for such permit to Glc a signed statement
that be is licensee pursuanuo the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area at
(commencing with Section 7000) of Division 3 of the Businss eand Podessimo CrNe) or
3 777
that ha is eacm,t themfman and the basis for the alleged esereption. Any vmlodoa of
Section 7031.5 by any applicant for a permit subjects me applicant o a civil penally of
3 2�SI2'Iilgl®fS
not more man rise hundred dollars (5500).
pan Type
I, as owner of the pmpcny, or my employees with wages as Meir sole compensation,
J(
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Pmfccsions Cash: The Contractors License Law does not apply to an owner of
Required Ins ections
property who builds or Missives thereon. and who does such work himselforthrough his
301 - ROUGH PLUMBIR
own cmpmyces,provide° mat such improvements are not intended or offered for sale. If.
303 — ROUGH MECHANICAL
however, me building or improvement is sold within one year of completion, the owner -
builder will haw me burden of proving that he did not wild or improve for purpose of
304 - ROUGH ELECTRICAL
sale.).
505 - FINAL ELECTRICAL
11 1. as owner of the property. am exclusively contracting with licensed contractors m
COMMuCt the Project (See.7044. Business and Professions Cine:) The Contractor's Li
507 — FINAL PLUMBING
came law does not apply to in owner of progeny who wilds or improves mnreon,and
who contracts for such projects with a contractor(s) licensed pursuant to be Contractor's
508 - FINAL MECHANICAL
License Law.
❑ I am exempt under Sec. , B k P C for this reason
Owner Date
-
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fallowing declarations:
1 ban and will maintain a Cenmca¢ of Consent o self -insure for WorkersComPen-
sation, as provided for by Section 37M of the Labor Code, for the performance or the
work for which this permit is issued.
❑ 1 haw and will maintain Worker's Compensation Insurance, as rtryuired by Section
3700 of me labor Code. for the performance of the work for which this Fmmit is issued.
M Workers Cmnpcnsation Insurance cart r and Policy M�i�n[t
�aam�::ayy��ysia�
CS 0. / Policy NO.yJ 6,Z_,{[_�� i
CERTIFICA OF EXEMPION FROM WORKERS'
COMPENSATION INSURANCE
Qbis section need not w completed if be permit is for no hundred dollars (S 100)
in Icss.)
I cenify mm in the perfomrance of the work for which this Permit u issued, l shall nut
emPlny any person in any manner air as m become Subject o the Workeri Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: IL after making this Ccnifeam of Excmptlon, you should
weonle subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall w deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm mat mere is com orctin t lending agency for the performance of
the work for which this permit is issued (Sec. 3W7, Civ, C.)
Lender's Name
Underi Address
1 cenify that 1 have read dais application and sum that the stow infprmatiun is
correct. 1 agree to comply with all city and county ominances and state laws totaling to
building Construction, and hereby authorive representatives OF this city to enter uPon me
anconseltm onca phe ,at far impaction purposes.
(We) agree to Sive, indemnify and keep harmless the City of Cupertino against
liabilid..judSmcnts.costsand ca sea which ma yin anyway accmc against said City
in conscyucnc of the 6mn'ng of sper
r
L,CA ANDS ND LL COMPLY WITH ALL NON -POINT
APURCER
Issued by:
ULDER0
Date
Re -roofs
ignorer Applic o mor Date
AZARDOUS MATERIALS DISCLOSURE
Type of Roof
OF the applicant ser future building occupant store ar handle hazardous material
. e n d by the Cupertino Municipal Code, Chapter 9.12, and Be Health and Safay
Cion 35532(a)?
❑Ycs
All roofs shall be inspected prior to any roofing material being installed.
W0l 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
L hazardous air conmminants u defined by the Bay Area Air Quality Management
t,tricl?
all new materials for inspection.
❑Yes ❑N[
1 haw react the havarmrvsmamrials requirements un@r Chaper695 alone Califor-
nia Health h Safety Cmk, Sections 25515.25533 and 25534,1 undcrsmnd mot if the wilding
docs not an=ntgy haw a ten k ma t is y respunsi nilily In notify the occupant of me
notimmmems wl'h ha st w et pd toi a,pecor a cerafe,m,5 Occupancy.
Signature of Applicant
7
Date
All roof coverings to be CInRR "n-, i,
er or honed agcm -fir n,,.
CITY OF
CUPERTINO
CITY OF CUPERTINO 0 3 `( >/
FURNACE/AC
PERMIT APPLICATION FORM
APN # �,
i
Date:
Building Address:
BREMFURN
Owner's Name:
Acne #:
AS Ft 0 NzA
-S8-osvi
ontractor: Phone:
License #:
,e- Pniz5-6 9-0 29 7
C9LO --4rl K. 277!7
Mogtact: Phone:
Cupertino Business L cense #:
c k S68-o:z9r/
BSEISMICRE
Building Permit Info:
BUILDING
Bldg ❑ Elect Plumb
Mech
Job Description:
MPERMITFEE
Mech Permit Issuance
MECHANICAL
Residential Commerci ❑
Plumbing Permit Issue
For Residential Installations:
BPERMFEE
Attic ❑ 151 floor ❑ 2"d floor ❑
BUILDING
Adhere to min set back requirement ❑
Plan Check Fee
For Commercial Installations:
BUSLIC
Replacement same weight ❑ Additional weight (structural calcs) ❑
BUILDING
Structural Calculations required for new installation ❑
Newinstallation Plannin A roval Required El
Cost of Pr It Type of Construction:
Occupancy gr 2
Strapped P 96 1?1 fo ❑ Bonded ❑
Sq.Ft. Floor Area:
New Location ❑ Re lacemn� t "
Qty. if
ADDlicable.
FPP M
Foo Tle ..w:
BE RG
Energy
rw vIvu
BUILDING
BREMFURN
Relocation of Furnace
MECHANICAL
BREMAMOVER
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