03090128 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT GONTRACTORINFORMATION9th.°
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ou ILDING ADDRESS: VALLEY HEATING Sc COOLING PERMIT N003090128
Arg WTT,KTTjq()M AIT
OWNER'S NAME: 1171 N 4 TH ST PERMIT ISSUE DATE
FRIEND PATRICIA J 003
NE: (408) 294-6290 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I DO LICENSED CONTRACTOR'S DECLARATION
of ION
F 1 hereby storm mat 1 am Goosed under pmvixiI of Chapter v(commencing Job Description
wimScnion]ll(X))afDivision]afineBusiness dPrufessinnsCode.antlmylicensos ww,, pp ��oo
>�? iamB rc a=dery t. G f��/G REPLACE FURNACE F1,YALED
q Lican s Lic.«
+yq Date Curer r �! �/«'rti-uL
pp7W ARCHITECTS A ION
NOVIK lir and my plansahallhcused M publiemeords IYoY 92003 yap 'Y Y
7to.
Licensed Pr..fcssional
OWNER-BUILDER DECLARATION /�
i a E 1 hereby affirm mat 1 am exempt from me Contractor's License Law for the BUILDING
following reason.(Search 7031.5.Business and Pm(casions Code:Any city or coca,
m which requires a permit at construct,elmq improv.demolish.nr repair any swcome
^iY prior to its issuance,also requires the applicant for such permit to file a signed statement 82200
ESG that he is licensed pursuant toOkpmvisiomofthe Commcwr'sLicense Law(Chapter 9 Sq. Ft. Floor Area Valuation
ill- (commencing with Section 700soof Division 3 of the B usin..v and Professions Code)or
rest he is exempt therefrom and the basis for the alleged emanuion.Any violation of 35613033 . 00
Semon 7031.5 by cry apprant tor.pehnit subjects the ep,haam to.civil penalty of - .APN Number - Occupancy Type
not more man five hundred dollars(t5007. - - "' - "" - - p y ---
❑I,m owner of the pmperty,or my employees with wages as hre;r sole compensation,
will do the work,and the structure is nut intended or offered for sale 7644,Business —
and Professions Code:The Contractor's License Law does not apply to an owner of 3 0 3 - ROUGH b4
ons
property who builds or improves thereon,and who does such work himself or through his L
non employees,provided that such improvements are not intended or offered for sale.Ir. 304 - ROUGH ELECTRICAL -
however,the building or impwromat Is sold within one year Of completion,the owner.
builder will ban the burden of preving tat he did not Wild or improve for purpose of 505 - FINAL ELECTRICAL
"le')' 507 - FINAL PLUMBING
I,as Owner of me prop lay,am exclusively contracting with licensed contractors to -
construct the projem(See:7oaa,Business and Professions Code:)no contractor's Li. 508 - FINAL MECHANICAL
came Law does not apply to an Owner of property who Wilds or improves thereon,and.
who contracts for such projects wit a convactor(s)licensed pursuant o the Contractor's
License raw.
❑I em exempt under Sec ,B&PC for this moon
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury One Of she following declarations:
1307M
have and will maintain a Cenificate of Comens to selblmure for Worker's Campion
n,u provided for by Section 3700 of the Labor Coda,for the pcarommance of the
for which this permit is issued.
El have and will maintain Workers Compensation Insurance,as required by Section
of the tabor Calc,for Nc paAOrmmm of the work for which this prount is issued.
Worker's Cnmpensalinn Insurance carrier and Policy number am::er. 2P-g T-I-4 Policy NojQ�//O/
CERTIFICATE OF E%EMPf10M N..Aj KERS'
COMPENSATION INSURANCE SGP_�)
(This section need not W completed Ethe reimir is for one hundred dollars(51008
less.)
1 cenify that in the pemGOmanee or the work for which this permit b issued.l shall nos
employ any pawn in my manner so as to become subject to the Wurkori Compensation
Laws of California,DOW
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Compensation pmvisons a(the labor Code,you must
0O forthwith comply with such provisions or this perm it shall be deemed revoked.
Z Vy CONSTRUCTION LENDING AGENCY
1 hereby affirm mat them its connotation lending Rant,for the perfurnamee of
:4 the work fur which this permit I.issued(Sec.3097,Civ.C.)
4 QLeader's Nam.
1 z Lender's Address
Q 1 cenify that 1 have mad this City
and con and sine that the above nos relating is
1. U building 1 agree to comply with all airy and county ordinances and cute hwter upon
to
QU building coi...d construction,said hereby airman prapresenwiwa offlus city rocnurupnn me
G above-(We)agree to save fmimnify a keep s.
(We)agmen to save,indemnify and kith hay in b the City ar against
ad city s.
r N a consequence
of
coarsing expcnusm it. may in any way eccmc against said City /
;J 7 A consequence of UNDERSTANDS
Of this permit.
t� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO CE �GUL ION
q I7 d0 Re-roofs
rgnaw'a of Ap icanVCan r Oa
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant at futum building oecupanutore or handle hazardous material
az gcfined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code,scion 2ss32(el? All roofs shall be inspected prior to any roofing material being installed.
❑tea �t4O
Will the 3PPIvAnGOf future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it marinas air contaminants m defined by the Bay Area Air Quality Management all new materials for inspection.
strict? ....
❑Yes f-1.Nu
1 have real me hasardaus materials requirements under Chapter&95 of the Caliror-
ria Heart&Safety Cade.Sections 25N13.25533 and 25534.I understood had,it der boding
does not currently how a usam,mar is is my mspomihiliiy to notify dm Occupant of the
acquire act fpd r;asuan.eor.C. mateoro.. a,, Signature of Applicant Date
a —� All roof coverings to be Class "B"or better
r or awhanrcd vgcm WE
CITY OF CUPERTINO
(IQ. FURNACE/AC
IT
CUPEIZTINO PERMIT APPLICATION FORM
APN# Date:
4 r O
Building Address:
1
Owner's Name- Phone#:
�1Iq r 1
Cont cton Phone: cen #:
5
Cof4ct: ` Ph Cupertino B siness License#:
N�
Bu ding Permit In • —/
Bld El ❑,Elect Plumb Mech Lr
Job Descripti . _ _
Reside ial` ommercia
For identialIn ations:
Attic oor- 2nd floor❑
• Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installatjpn Planning Approval Required ❑ i
Cost of Pr ' :� �; pe of Constructioq;-----,---, Occupancy grou
Strapped On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Re la em
Qt
A ica 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
1 71
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