06100061 7777777777777.:. __77-
CITY OF CUPERTINO
OU1LDING DIVISION PERMIT. ,+C� I'1 R CTQIt I�QRM. TIa�N:
PERMIT NO.
BUILDING ADDRESS: CONDITIONED AIR 06100061
10675 GASCOIGNE DR
OWNER'S NAME:
PERMIT ISSUE DATE
WILBUR SHARPE 1701 LITTLE ORCHARD ST in/in/2noe
NE:
SANITARY NO. CONTROL NO.
(408).291-2220
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION
v E- I hereby affirm that I am licenced under provisions of Chapter 9(commencing Job Description
Z U with Section 7000)of Division 3 of the Business and Professions Code,and my license is
<a in full force and effect. REMOVE AND REPLACE FURNACE & ADD A/C
Z License Class f a 7Vr Lic.# q,4�1 6
s— Date JU f U Contractor (b A -Aa rata h 14,1k
ARCHITECTS DECLARATION
a
U I understand my plans shall be used as public records
CA Licensed Professional
y OWNER-BUILDER DECLARATION
j a 1 hereby alTirm that 1 am exempt from the Contractors License Law for the
00 following reason.(Section 7031.5•Business and Professions Code:Any city or county
004 $8322 which requires a permit to conswct.alter,improve,demolish,or repair any structure
Z
In prior to its issuance,also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
t, (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of r 0 0 Occupancy Type
not more than five hundred dollars(5500).
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business ns Required Inspections
and Professions Code:The Contractor's License Law docs not apply to an owner of (1 P
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's U.
cense Law does not apply to an owner of property who builds or improves thereon,and,
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
Q I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation insurance carrier and Policy number am: I'C
Carrier. A) 710 ,�,�PA\ic�hPolicy No.: 01 W01�q{S
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
1 cenify that in the performance of the work for which this permit is issued.I shall Trot
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z RCONSTRUCTION LENDING AGENCY
[~-t CA I hereby affirm that there is a construction lending agency for the performance of
�.> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q
Lendces Name
aZ Lender's Address
U C) I certify that I have read this application and state that the above information is
uL correct.I agree to comply with all city and county ordinances and state laws relating to
O U building construction,and hereby authorise representatives of this city to enter upon the
above-mentioned properly for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
rF-t liabilities,judgments,costs and expenses which may in any way accrue against said City
U z in consequence of the granting of this permiL
►� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGULAM
$tet !v !y v b Re-roofs
aturc of Applscan AZARDOUS MATERIALS DISCLOSURE tor Doc Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes \
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes (--QN2
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant.that it is my responsibility to notify the occupant of the
requirements which must beim a prior to issuance of a Certificate of Occupancy. Signature of Applicant Date
iii "- f U -tU-cc All roof coverings to be Class"B"or better
Own authari-rcd agent Date
Community Development
10300 Torre Avenue
'- Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
7UPE�TINO
Building Department
JOB ADDRESS: PERMIT #
C� _ XJ
OWNER'S NAME: W t . y- S PHONE # ) /-
GENERAL CONTRACTOR: C6 n FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following info ation:
21 SUBCONTRACTOR BUSINESS NAME USINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation /
Fencing
Flooring: Carpeting
Linoleum/ Wood °f
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornament44heet Metal
Painting,/Wallpaper
Paving'
P14 ening
umbing
f Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Z,--) .,/6 z(�,/-- J,"-I�, /o <<1 o
dwKe a Date
CITY OF CUPERTINO Guo l uaao\
FURNACE/AC
JINO PERMIT APPLICATION FORM
APN# rD of
Date:
Building Address:
%NNC so I
Owner's Name: Phone#:
Contractor: Phone: License
�. .
Contact: Phone: Cupertini ;Business License#:
Building Permit Info:
Bldg ❑ Elect `8-- Plumb L7 Mech
Job Description:
G?
Residential �_ Commercial ❑
For Residential Installations:
Attic ❑ 1'floor ❑ 2nd floor❑
Adhere to min set back re uirement
jr Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required
Cost of Project: Type of Co ction: Occupar. y grou
Strapped On Platform C1 Bonded Sq.Ft. F or Area:
New Location &---Replacement 1;1e,
Qty. if
Applicable Fee ID Fee Descri tion Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfin MECHANICAL
BREMAIRHAN A/C Units<= 10, 000 cfin MECHANICAL
BREMRECEPT RecPtl, Switch&Outlets ELECTRICAL
( BSEISMICRE Seismic Fee Res I BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PERMITFEE Plumbing Permit Issue PLUMBING
♦ BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee., BUILDING
BPGAS Gas Piping System Fee PLUMBING
BUSLIC Business License BUILDING