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04050140 (2) CITY OF CUPERTINO "'' BUILDING DIVISION PERMIT Ci7NTRACT,R INk'El"ttMATIO,N s. .noS�'# .<f`. BUILDING ADDRESS: A B S HEATING & AIR COND 'on MIT"°04050140 214 7 111T IT OWNERS NAME: PERMIT ISSUE DATE JOHN LEMONS ONE: SANITARY NO. CONTROL NO. (408) 238-7178 ARCHITEC(ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH sett LICENSED CONTRACTOR'S DECLARATION Job Descri [100 mp I hereby affirm that I am licensed under provisions of Chapter 9(commencing p iW with Section7"duf Division 3 of the Broadcast and Professions Code,and my license is „ mmumreeandmrree -� �(�`�'� ADD A/C r-QDQLWD �z ucrnse las Lim.» —❑ Dam -2 - Conrecnr Q• RAMII&ha eq� ARCHITECTS DECLARATION Y Q Iunderstand myplans shall heused aspublic records $77 7 2004 c.�yU " Licensed Professional0 � .�a OWNER-BUILDER DECLARATION ZULU I^I� 2 e 0 I hereby affirm that I em exempt from the Contractor's o License Law per the V�LI��J i cO following mason.(Section](131.5,Business and Professions Code:Any city ns county m� which requires a pcmit to construct,alter,improve,demolish,or repair any structure prior to its issuad...also torches the applicant for such perminu the a signed stir mens —�< thal he is licensed pursuant to the provisions of the Contractor'sLicense Law(Chapter) Sq.Ft.FloorArea Valuation ni G (commencing with Section]B(IB)of Division 3 of the Business and Promusinns Code)or i 3 Nat he is exempt therefrom and he basis for Ne alleged exemption.Any violation of qtr Section]031.5 by any applicant for a Permit subjects to applicantto a civil penalty of 3(AT1 364bbcr00 Occupancy Type not more Nan five hundred dollars(5500). ❑1,Mowner of the properly,or my employees with wages as their sole compensation, will do the work,and Be swcture isnot intended or offered for sale(Sec.7004,Business and Professions Code:The Contractor's License law dors art apply to an owner of Required Inspections property who builds orimproves Brown,and who doessuch work himself or through his own employees,provided that such improvements...I intended ser offered farsale.If. Miniver.Ne building or improvement is mid within one year of completion,to owner. builder will have me burden of proving that he did not Wild or improve for purpose of sale.). ❑1.as owner of the property,am exclusively contracting with licensed comem ors to construct the project(Sec.7044,Business and Professions Code:)The Conmemr's Li. cense Law does not apply to an owner of property who builds or improves income,and who contents for such projects with a comraceacha licensed pursuant to the Commerce, License Law. I as exempt under Sec. ,B&P C for this mason Owner Data WORKER'S COMPENSATION DECLARATION I hereby affirm under Penalty of perjury one of the following declarations: 1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen- 7rC1111 ion,ao provided for by Section 3]00 of the labor Code,for the performance of the rk for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance,u mquired by Section 0 of Ne Labor Code,for the performance of the work for which this Permit is issued. Wor/kkee7�rr''sesyyC��om�p^en,sNmion Insurance carrier and Policy nnuumGb�eerr aro: ricr:l'CPo RVI/ �b Policy No.:RJS I I�?, a I CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not becompleled Hthe permit is for one hundred dollars($IN)) or less.) I comfy mat in the performance of the work for which this Permit is issued,I shall not employ any Person in any mann�tsoi 9.r- b me subject to the Workers'Compenson 1ati Laws of Cs�k �� At Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker'a Compensation previsions of me Labor Code,you must .JOforthwith comply with such pmvisiona or this Permit shall be decmcd revoked. Z CONSTRUCTION LENDING AGENCY 04.>-� I for Which Yarm Nat New is a ed(See 097. agenry l'm to perfumamen of a the work for which this permit is issued(Sec.3097,CO.Civ.C.1 W Q Lender's Name Z Leaders Address U,J 1 arty that 1 have mad this application and stare Nat the above informmiun is W F bunging 1 agar toconstruction.comply with ell city and mpeco ordinances and mate laws relating le / DV above-mding tionerand hcenMecliby onpurposescnutiwsof his city teenter upon the r W above-mentioned again property for inspection purposes. (We)eg a to eve,indemnify and keep harmless Ne City action against against UZ liabilities.judgments,costs oadiand g expmtsesmit. may in any wry ecrncagainst said City C)Z A APPLICANT of the UNDERSTANDS of this permit. r. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINT Issued by: Date WaEGULATIONS. Uk.- 6.24-04 Re-roofs Signature of Applica1100mornmon Dab: HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cepenino Municipal Code.Chapter 9.12,and the Health and Safety Allic-dO.SectioYes �No n 25532001 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 nit havaNnus air commonann as defined by the Bay Arca Air Quality Management all new materials for inspection. Dltria? ❑Yes faNu 1 have read the ha arJnus materials requirements under Chapter 6.95 of the Calhor, nia Hot&Safety Coda,Seedoee 25505,25533 and 23534.1 undersand mmif Ne building docs not currently haw a tenor Nal it is my responsibility to notify the occupant of the r�cWy�m/m��gos whim must be met Pnor m ISSUMCO of a CCnlfibam ser OsCWcy. Signature of Applicant Date """"r �_ D.. All roof coverings to be Class "B" or better Owner m authorized apem Dam a,, !-Fd Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408) 777-3228 IITFax(408)777-3333 CUPEkTINO Building De artment JOB ADDREPERMIV# Z �.li cl PL_ nlo50140 OWNER'S NAM j,j S Mee PHON V1 - Z5-7.3 GENERAL CONTRACTOR: A -65, {p�� t) ik (2xoa FAX # :'W`r/l I am not using any subcontractors04�— 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 nn Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile -, 2 �j O r/Contractor Signature Date y 10/28/03 o 0�Y CITY OF CUPERTINO tgn FURNACE /AC o CUPEkTINO PERMIT APPLICATION FORM APN # ^ Date: Building Address: z l 4 k 1 �L Owner's Name: Phone#: 14 Q = tis 7z5 - z�z3 Contractor: � License#• C.Q `7 .d.�. 14gr1Nc z Contact: Phone#� I Applicant/Contractor: Building Permit Info: Bldg Elect Plumb Mech Job Descriptio Residential ,X Commercial: Sq.Ft. Floor Ar a: $/ q. t.: Architect/Engineer: Valuation4 Type of Construction / upan /r up:^ /C Qty. if Applicable Fee ID Fee Description Fee Group BREMFURN Relocation of Furnace MECHANICAL BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL BREMMISC Misc Apparatus ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE plumbing Permit Issue PLUMBING BPERMFEE Bldg Permit Fees BUILIDNG BPLANCHK Plan Check Fee BUILIDNG BUSLIC Business License BUILIDNG