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04090026 CITY OF CUPERTINO ' 4UILDINGVIVISION PERMIT" CONTRACTORINFORMACION .a.N.:i� BUILDING ADDRESS: PERMIT NO.04090026 4090026 OWNER'S NAME: PERMIT ISSUE DATE CITY OF CUPRRTINQ NE: SANITARY N CONTROL N0. ARCHITECDENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH (� uo c LICENSED CONTRACTOR'S DECLARATION 1 Mosby affirm Nlire es 1 am mcd under previsions of Chapter 9(mmmcncing lob DescripC M with Secure 70006 of Division 3 of the Bicenmaand Professions Code,end my license is in fell to.and aFt_•n HVAC/GFC I nce"!Ids Lia.• Da¢ — CunOR ,e A CH11 he usS as T1 �'`r �Y .,j p6 if/d OCT 15l 2004 y s< I understand my plans shall M used as public records ;QU Licensed Prarcssiontl 1 I'�® _ OWNER-BUILDER DECLARATION V i12 E 1 wrathy affirm that 1 am exempt from Use Contractors Liecnta law for the O o following meson.(Section 1(n 1.5,Business and Professions Cade:Any city or county _ K$ which requires a permit to construct,titer,improve,demolish,or repair my southern Na n F�fY^ prior N its issuance.&N.requires the applicant far such permit In file a signed statement �O the,he is licensed pursuant in the pmviaiom of the Coniacmri License Law(Chapter 9 Sq.Ft. Floor Area Valuation (commncing with Seedon]fD07nf Division Jof Ne Busineaand Profcuirm GaM)rl 59 9 Nat hails tempt theafrom and the bas,for de alleged easmplion.Any violation of Section 7031.5 by any applicant for a permit subjects On applicant to a civil penalty of 3 9a?l9 M®16er 0 0 Occupancy e net mare sun five hundred dollars(WOO). P y�T xy P 0 1,a owner of the pohNny,or my employees with wages as Nelrmic compensation, will do Newmk,and On structure,is notintanded oro@red formic(Sec.7044,Business and Professions Code:The Conuacmrs License law does not apply to in owner of Required Inspections pmpeny w ho builds rr im pmvaa Nemo n,and who dues such work h imal f or through his Own employees,provided Ihmsuch imprewmenu are not intended ereRemd forale.If, however.the building or improvement is said within one year of completion,the owner- builder will Mae to burden of pouring that M did not Wild or improve far p.m.of ale.). 0 1,an Owner of the property,am exclusively contracting with licensed mnmemra to construct the pmjeet(Sec.7044.Business and Paefessinm Cade:)The Contractors Li- am law does not apply to an awter of property wait Wilds or impose Osman.and, who contracts for such projects with a carllralar(s)licensed pursuant to the Comity Ora Lice has Law. 0 l am exempt under Sac. ,B&PC for this reason Owner Data WORKER'S COMPENSATION DECLARATION 1 hemby alBmr under penally of perjury arc of the fallowing declensions: have and will maintain aCcalficam ofConsem m self-imam far WmkersCampen- setion,m provided(or by Section 7]00 of N e Lobar Code.for the performance of the wok for which Nil perm,is issued. 0 1 have and will maintain Workers Compensation Imurace,as required by Section 3700 of Oc lab"Code.far Ne pedis macc.f the work fm which this Permit is iaosd. My Workers ml on Insurance carrier and Polity nu bar art: Cartier. Policy N ` O q/ L CE TAA..PTION FROM wOR E S' COMPENSATION INSURANCE (Th,secsion heed not becampined if IM permit Is forone hundred dollars(giro) at lcm) 1 certify Nat in the perfershome of Nes.,it for which thin permit is leaned,l shall net employ any person in any manner so a to become subject to On Worlucat Compensadan Laws of California.Data Applicant NOTICE TO APPLICANT:If,after making N.Ccnifirlc of Ewnh,lim.you Nuuld become subject to the Worker's Compensation provisions of the Labor Code,you most .,O forthwith comply with such"time.,or this permitahall M claimed revoked. Z N CONSTRUCTION LENDING AGENCY [—r Ihereby affirm that Nem is a construction lending agency for the performance or CG Nc work fur which this permit u issued(Sm.3097,Civ.C.) QLendces Name z Lenders Address J 0 I really that 1 have read this epidicatic n end sue that the above information is ' correct.I agree to comply with ail city and county oNim ecru and site laws relining to O Ir.'J building construction.and hereby authome representatives of this city in enter upon Nes t27 aleve-mentioned pmpeny for impcctian purposes G (Wes)agree to sane,indemnify ad keep homeless the City of Cupertino against l4 liabilides,Judgments,creta and expenses which may in any way acme against said City U 7 in consequence of Ne granting of Ibis permit. r� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date S0 R GULATIONS. o �iox� Daric Re-roofs brignature or ApplicanaConlnct., Data HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future Wilding occupsm stoic or handle hva dour nu mdal az defined by IM Cupertino Municipal Code,Chapter 9.11,and IM HcaIN an Safely Code,Section 25531(¢)? ❑tire ON. All roofs shall be inspected prior to any roofing material being installed. / 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 (•r— I hazardous air contaminants as defved by the Bay Arm Air Quality Management all new materials for inspection. slrin7 ❑Yes ❑Nu I have readtheh adeas materials requirements under Chapter 6,95ofthe Califor- niaHmlth&SafctyCocc,Sectiau 25505.15533 and 25534.1 terminated Nos ifNc Wilding dam not currently new a¢mac Nat is,my mspomibilay in notify the oceupart of Ne rwuimmemewhiahmurrx atpdarmiamnaarfaccmncaworampacy. Signature of Applicant Date e-- Dam All roof coverings to be Class "B" or better weer tar eushorizcti agent CITY OF CUPERTINO ��� W? FURNACE/AC UPERTINO PERMIT APPLICATION FORM IAPN# JC.- 7 / © � Date: J (OF uilding Address: / / /i Owner's Name: Phone#: Contractor- Phone: License#: /� Contact: Phone: Cupertino Business License#: Building Permit Info: ,,((, BldgEl Elect 1i Plumb El Mech Pk. Job Descrip 'on' R n1S C clG e�nove �_ / va � 1 Residential ❑ Commercial For Residential Installations: Attic ❑ I't floor ❑ 2nd floor❑ Adhere to min set back requirement❑ r Commercial Installations: eplacement same weight ❑ Additional weight (structural calcs) ❑ Structural Calculations required for new installation ❑ New installation PI ing Approvgj quired ❑ Cost of Proj 7c & l ,Type of Construction: Occupancy group: Strapped On Platform ❑ Bonded ❑ Sq.Ft. Floor Area: New Location ❑ Replacement ❑ Qh• 1 A 1' a e Fee ID Fee Description Fee Group BENERGY EnerRv 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 MPERMTTFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPLANCHK Plan Check Fee BUILDING BUSLIC Business License . BUILDING Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408) 777-3228 0'mo, Fax(408)777-3333 �UPERTINO Building Department JOB ADDRESS -Ij ^ p E IT# OWNER'S NAME: PHONE # 0 8 a GENERAL CONTRACTOR: E 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 �er/Con�tractorignature Date