03100133CITY OF CUPEWUNO
Buu.ntrgc ntvlsloN PERMIT
CQNTRACTOR INFORMATION ''
n:9' •A a .,fS3 .I c c,
B ILDING ADDRESS:
PERMIT NO, 03100133
OWNER'S NAME:
PERMIT ISSUE DATE
NE:
SANITARY NO. CONTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Chapter 9
lob Description
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I beceby affirm that 1 am licensed under previsions of (commencing
with Section 7M)) of Divl[lon 3Of the Business and Professions Code. and my Beer. is
in run fora and effect.
License Class Lic.as
FURNACE R Ii
Dale Comracur
ARCHITECTS DECLARATION
1 understand my plans shall he used as public records
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Licenced Professional
OWNER-BUILDER DECLARATION
Y:21
I hereby .(Sere that 1 exempt from the Contractor's l Licence Law far the
following moron. flection 7031.5. and ore Code: Any city st county
1. my
t, attar.
which rtyuirta a permit m construct, alter. impmw, demolish, .r repair any structure
w. de
prior m its issuance, also mquims the eisima, Of far such pcnnit m Ne Law(Chapter
thsspromem,.41 purism mthcpmviviio Ofnfc COmncmrsnd
Sq. Ft. Floor Area
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``•`J �/ 1 Valuation
(co mmencingwish Section Prof ionsCap¢r9
Pr.fAny
11
LZ.
and)thOiasis f3 the icGMc)or
Nat he u stamps therefrom and the buss for die tllegcd exemption. Any violation of
3 6 2 2 4 0 5
APN Number
Occupancy Type
Section 7031.5 by any oppressor for a perils subjects she applicant to a civil penalty of
not mom Nan Ew hundred dollars (5500).
❑ I, as owner of tlu pmperty, or my employees with wages a Heir sole compensation,
Required Inspections
will do Ne work and ate structure is not intended M.frond raraal. (See. 7014, Business
and Protrusions Code: The Comracmes Liave Law does not apply as an owner of
property who builds or improves thereon, and who doessuch work himself orthreugh his
own employees, provided that such impio o menu art not immoral .,offered fmssle. IL
however the building or improwmem is sold within one year a( m innounn, she owner-
builder will Mw One burden of proving that he did ons build or improw for purpose of
-
ezdmia contracting with licensed common t.
vr I, as ower of the pale
,
704. B
the project (Sec. x4. and The. ri Li
and Prafeh.
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Wi d. a,is
the
cove Low does not apply je m owner of preperty who builds or imPmves Norton, and,
Mae Lo s was, f
,
for such project with aconuacmr(s) licensed pursuant m Ne Cantnnors
whence
License Law.
Law
❑lam exempt under Sec.
,B&PCfor this reformOwn---'—'�_''
Os Da
WORK ERS COMPENSATION DECLARATIO
1 hereby affirm under penally of perjury one.f the follow mg declarations:
r
1 hew and will maintain a Certificate ofc.nsem to self-insure for WorkeM1 Com ort-
sati.n, as provided for by Section 37W Of Thr Labor Code, for the peour amce rime
work for which this permit is issued.
1 haw and will maintain Worker's Compensation Insurma, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is sussed,
'
My Worker's Compensation Insurance tinier and Policy number em:
Cartier: Policy No.: _
CERTIFICATE OF EXEMP71ON FROM WORKERS'
COMPENSATION INSURANCE
This section need not he completed If she Permit Is forme hundred dollen (11(10)
or Iota)
I candy that in the performance of the work for which this permit is issued, l shall not
employ any p.rs.n in any frontier so as to WCOme Stablest to the WOrken' COmPnts.ti00
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
Weare subject t. she Worker's Compensation Provisions or the Labor Code, you must
forthwith comply with such provisions of this permit mall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that them it construction lending agency for the performance Of
the work for which this permit Is issued (Sec. 3097. Civ. C.)
Lenders Nem.
Lamm's Address
I cenify that 1 haw read this application and sou Net In, show infmmatiun is
ormoct. I agree to comply with all city and coumy ordinances end mu laws relning to
building construction. and hereby minotim represematiw Of this city to enter open the
.hew-mamitmad pmp.fty far Inspection purpoces.
(We) agree to taw, indemnify and keep harmless the City of Cupertino against
1
liabilities, judgments, costs and to penes which may in Boy way accrec against said City
in consequence of Ne gra ling of this permit.
C
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Type of Roof '
— - " / 0 7 p?
_
gra r ofAppbcaH ZARDOUSMATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle ha mous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and tie Health and Safety
J e. Section 35533(.)?
❑Yu Nits
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant at future building Occupant use equipment or dcvias which
it hamrdnus air c.Oumin sus u defined by the Bay Area Air Quality Management
all new materials for inspection.
trier?
❑Yes 0l Nu
Id
1 have mW the hN
aesauss materialsmI.Mena usumCr Chapter 6.9Softh. Califon
Health & Safety Code, Sauuns 25303, 23533 end 2553x.1 understand thd ifdte Farilding
n not currently haw a unam, Nm
Net it u my responsibility notify the Occupam or the
Ointments which must Is, met prior to issuance oft Certificate of Ocaput y.
Signature Of Applicant Date
All roof coverings to be Class "B" or better
ov,ne, h.rind.s.nt
,
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Cm OF
CUPEkTINO
CITY OF CUPERTINO
FURNACE/AC �`�
PERMIT APPLICATION FORM
APN#
Energy
Building Address: 2603
BREMFURN
Relocation of Furnace
MECHANICAL
Owner's Name: X -L4 0 tm/✓ '2�/v
Phone #: 7 p 6Q
0
Contractor: Phone:
License #:
Contact: Phone:
I
Cupertino Business License #:
Building Permit Info:
Rec tl, Switch & Outlets
Bldg ❑ Elect_ ❑ Plumb ❑
Mech ❑
Job Description.
/i
BUILDING
Residential Commercial ❑
/
J
For Re idential I Mations:
MPERMITFEE
Attic I" floor 2nd floor ❑
MECHANICAL
Adhere to min set back requirement ❑
Plumbing Permit Issue
For Commercial Installations:
BPERMFEE
Replacement same weight ❑ Additional weight (structural calcs) ❑
BUILDING
Structural Calculations required for new installation ❑
Plan Check Fee
New installation J?lanning ApEroval Required
\
Cost of Projec Type of Construc6 n
Occupancy
^
Strapped ❑ L On Platform ❑ Bonded
Sq.Ft. Floor
New Location ❑ Re lace
Qty. if
AnvYicable
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
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