03100153 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAC-TOR INFORMATT ION:
BU ILDING ADDRESS: A & H HEATING PERMIT NOO 3100153
OWNER'S NAME: 770 CHESTNUT STI. PERMIT ISSUE DATE
10/21/2003
ONE: (408) 279-0722 SANITARY NO. CONTROL NO,
ARCHITECfIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECN
100 LICENSED CONTRACTORS DECLARATION
m I are6y affirm that I am licensed under pmviaiom of Chapter 9(commencing lob Description
4
with rcSection IXIU)nf Division]of NC Business mAProfcssiom QsJe.end mylicemc is /
ap� in full forces IM),
V L REPLACE FURNACE
>q? License CI Luc.Y
�F Dale ` ConlfaCbl
ARC TEC(5 D ATIOI
M
U I understand my plain shall a used aslubif.ne..... O/
c0. Licensed
jo d POWNER-BUILDER DECLARATION
<I 1 hereby affirm that I am exempt from the Contractor's License Law for the
O o following mason.(Section 703 LS,Business and Professions Code:Any city or county
5$ which requires a permit to convect,alter.improve,demolish,or repair any structure 14 0 0
-le poor it)its issuance,also requires the applicant for uch permit to file a signed statement
ezp that he is licensed pursuant to the provisions of the Contractor's License Law(Chapmr 9 Sq.Ft. Floor Area Valuation
ZF (commencing with Section 7OXE of Division 3 of the Business and Professions Code)or
$ Nat he is eumpt thcneftom and she bets for Ne alleged exemption.Any violation of 35915028 . 00
Section 7031.5 by any applicant(at a permit subjects the applicant to a civil penally of APN Number Occupancy Type
not more Nan Eve hundred dollars($500). P Y YP
0 I,as owner of the propcny,or my com loycm with wag"as their sale compensation,
Will do the work and the annum i$not intended or olrened tonal.(Sec.7044,Business
and Professions Code:The Convector's License haw does not apply to an owner of Required Inspections
property who builds of improves thcneon,and whodmamch work himself or through his
own employcm,provided that such improvements ate not Intended oralfered for sale.If,
however,the building or improvement is sold within one year of complefion.Ne owner
builder will have the burden of proving Nal in,did not Wild or impraw for purpose of
ale,7.
❑1,as owner of Ne propany,am exclusively contracting with licensed moue me to
convect the project(Sec.7044,Business and Professions Coda:)TO,Cmirmcmr's It.
come Law does not apply to an owner of property who builds or improves Ihemon,and
who contracts for such projects with a contactoru)licensed pursuant to the Contractor's
License Law. -
I am exempt under Sec. .B k P C for this fooden
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hemby aBhm under penally of perjury one of the following decluetions:
1 have and will maintain•Cenificam or Consent a sal Dinmrt for Worker's Compere
70171W'
on,as provided for by Section 37(111 of the Labor Code.for Ne performance of the _
rk for which this pertnil is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section
of the labor Code,for the performmce of dre work fm which this permit is issued,
Workch C pemetion Imunnce artier and Policy say pq art:. a motion 7 Policy No.: / lI�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this aced.need net a completed if the permit is for one hundred dollars(5100)
or less.)
I certify that in the Pcrbioname of the work for which this permit is issued,l sail not
employ any person in any manner an m in emore mbjmL to IM Workni'Compararion -
Laws of California.Date
Applicam
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Cale,you must
7Q forthwi th comply with such provisions or this perm i adult the decreed revoked.
ti y CONSTRUCTION LENDING AGENCY
I abhy alum that Nem is a eonstruetino lending agency for to Performance of
the work for which this permit is issued(Sec.309'1,Civ.C.)
YQ Lenders Name
Z Lender's Address
Q I cenify that 1 haw mad this application and Marc that the above information is
y f" correct.I agree to comply with all city and county ordinances end state laws misting to
�(J building convection,and hereby auNofire representatives of this city to enter upon the
W ahovo-mcrujimed properly far impenion pmpmes.
gy (We)agree to ave,indemnify and keep harmless the City of Cupertino against
fn IiMil ides.judgments,casts and expenses which may in any way accrue against aid City
JZ in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS ANP WILL COMPLY WITH ALL NPO Issued by: Da
SOURC REGULATIONS.
Re-roofs
mbfe of ApplicantlComracbr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applimm tar fubm building occupam stone or henJlc hamrdous material
as defined by the CupeAno Municipal Code.Chapter 9.12,and the Health and Safely
rate.senior 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Yea
Will,
the appbamr
Or mem building Occupant .gaipm.nt pfd devices wM.n If a roof is installed without first obtaining an inspection,I agree to remove
it I ammous air Comamimnls a definml by the Bay Arta Air Quality Managcmemt all new materials for inspection.
❑Yes Nu
I have mad the haamnus materials requirements under Chapter 6.95 of the Cali for
hie Health 6 Safety Cole,Seeuons 25505.25533 and 25534.1 underhand thhdue,building
Joe net currently ban a omml,that it is res aibiloy m notify to oacupml of the
regxireme whichmuslW poor raCesufimbo eo e. ignatureOfApplicant Dale
net or authorised as cm ,te All roof coverings to be Class"B"or better `''�
St4lj J_ ` •
CITY OF CUPERTINO "
FURNACE /AC 3 � �'' G ��' .• <
" sT pryuPEkTiNO PERMIT APPLICATION FORM
., `APN # Date:
cu
:Building Address:
7 . ,.t -JAW4Y M
Owner's Name: Phone#:
._ ILS 0?5,2 -4 9r9
! Contractor: - License 4P '
,Contact: Phone #
DALENE 0
S a 74-p74I X
i
S p t Mpplicant/Contractor: DA r
,t,RT.Building Permit Info:
�j.-;, Bldg Elect Plumb Me
�4 -Job Description: ( },
Residential: b 4� t�Yv C Commercial:
..
t Sq.Ft. Floor Area: $/Sq,Ft.: -
--Architect/Engineer: Valuat n:
gp6)
ype of Construction: Occup cy Group:
r2C.
w: . Qty, if
iAppligaWe, Fee ID Fee Descri tion Fee Group
BENERGY Energy BUIIIDNG
z.,,
;t? '; 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. .
r.;
it BSEISMICRE Seismic Fee Res BUIL.IDNG
'6t' � '
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL:
i> PPERMITFEE Plumbing Permit Issue PLUMBING
s.
BPERMFEE Bldg Permit'Fees BUILIDNG
f+ " BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License Bt IL DNG
2 ,3S -3