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09030169 CITY OF CUPERTINO PERMIT BUILDING DIVISION PERMIT � � � � � PERMIT NO. BUILDING ADDRESS: 21584 CASTLETON ST AAA FURNACE & PERMIT ISSUE DATE OWNER'S NAME: CONDIT:=ONING ADNA `' SA CONTROL NO. O BUILDING PERMIT INFO ARCHITECUmNGINEER: BLDG ELECT PLUMB MECH RPLCMN`[' OF EXT FURNC & A/C D O O D Q04 z OO LICENSED CONTRACTOR'S DECLARATION INSTLTN & INSTLT OF Job Description U I hereby affirm that I am licensed under provisions of Chapter 9(commencing -Z m with Section 7000)of Division 3 of the Business and Professions Code.and my license is n e a in full force and effect ^ / ZLicense Class Ls JJ:7 t Lie./ n F a Date a_Z 4—Q Contractor !-fit l/3"� Lu ARCHITECTS DECLARATION Cd_<1 I understand my plans shall be used as public records 0. g U.H Licensed Professional A201 rA OWNER-BUILDER DECLARATION I hereby alTirm that 1 am exempt from the Contractofs License Law for the p O following reason.(Section 7031.5,Business and Professions Code:Any city or county 4 m 9 which requires a permit to construct.alter•improve,demolish,or mpair any structure 4—r prior to its issuance.also requires the applicant for such permit to rile a signed statement S Ft.Floor Area Valuation < that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 (1 t= (commencing with Section 7000)of Division 3 of the Business and Professions Code)or y that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number not more than five hundred dollars(5500). 1,as owner of the property.or my employees with wages as their sole compensation, will do the work and the structure is not intended oroffered for sale(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law does not apply to an owner of 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.). O 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li- 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. ❑1 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: 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. I have and will maintain Worker's Compensation Insurance,as required by Section 37W of the Labor Code,for the performance of the work for which this permit is issued. My Workees Compensation Insurance carrier and Policy number am: Carrie C�Pn V!I"--r44 Policy No.: CERTIFICATE OF EXEMPTION FROM WORKER COMPENSATION INSURANCE (This section need not be completed if the permit is formic hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued.I shall not employ any person in any manner so is 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 to Labor Cotte,you must Oforthwith comply with such provisions or this permit shall be deemed revoked. Z Z CONSTRUCTION LENDING AGENCY Cf]F.n o-r I hereby affirm that there is a construction lending agency for the performance of (Yy> the work for which this permit is issued(Sec.3097,Civ.C.) W A Lender's Name 0 z Lender's Address 1 certify that I have read this application and state that the above information is LUL correct I agree to comply with all city and county o . cea and state laws relating to 0 U building cortswction,and hereby author;-rep ta' of this city to enter upon the W above-mentioned property far inspecuon pu s a (We)agree to save,indemnify and less the City of Cupertino against p.4� liabilities,judgments,costs and expenses w ch y in any way acme against said City V Z in consequence of the granting of it. Date •3 �� ►+ AP UNDERSTANDS L COMPLY WITH ALL NON-POINT Issued b�: UR RE U AMONS. ' j 2Y- Re-roof: — Signat ApplicanUContractor Dae T of Roof HAZARDOUS MATERIALS DISCLOSURE Type 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 roof:;shall be inspected prior to any roofing material being installed. Yes ONo Will a roof is installed without first obtaining an inspection,I agree to remove ll the applicant or future building occupant use equipment or devices which At hazardous air contaminants defined by the Bay Area Air Quality Management all new materials for inspection. Jislrict? 0 Yes ❑No 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Cade,Sections 25505.25533 and 25534.1 undcrsuand that if the building urtcntly a tenant,that it is my responsibility to notify the occupant of the requireme ust be met prior to issuance of a eninc�ate of Occupancy. Signatur:of Applicant Date 2 ,c r. All roof coverings to be Class ,�{. or better Ow authorized agent Date 01 CITY OF CUPERTINO FURNACE/AC CUPEkTiNO PERMIT APPLICATION FORM APN# 35 Date: �, a cxDq ` C5 - Z 3 -0 7 Building Address: S,5 y C cc S � l e+v iu S e 1- (u Pe",�7 r`' C Owner's Name: Phone#: l 2-7 -3 Contractor: Phone#:406- - ;L91 3 -q? 2 0%)A C- j-�jC, Fax #: 4-0�- - 913 - 4, 7 - Contractor License#: Cupertino Business License#: 7 to Sr-V Contact: G G e Z Phone#: ZA Fax#: Building Permit Info: Elect 1Z1, Plumb [Y Mech Residential R Commercial ❑ Job Description: l U C P rye e i J O cx# S:b "5 Ic h v'-' iN /l For Residential Installations: Attic ❑ ls` floor [r 2 n floor El Adhere to minimum setback requirement For Commercial Installations: Replacement same weight ❑ Additional weight(structural calcs) ❑ Structural Calculations required for new installation ❑ New installation Planning Approval Required ❑ Cost of Project: .9V 2,, d p(7, 0 Type of Construction(Usage Class): u(� Strapped ❑ On Platform ❑ Bonded New Location❑ Replacement-D-- Valuation: Green Building: Must attach Green Building Check list to this application CITY OF C UPERTINO FURNA.CE/AC CUPEt �TINO FEE SCHEDULE Quantity Fee ID Fee Description. Fee Permit Type Group FURNACE FURN/AC 1MCRAA Commercial-Repair/Alteration/Add to M ea heating appliance,refrigeration unit, cooling unit,absorption unit,or ea heating,cooling,absorption or evaporative cooli:ig system,incl installation of controls regulated by this code. 1MCREPALT Commercial for tie repair of alt/add to M ea heating appliance,refrigeration unit,cooling unit;VAV boxes, absorption unit or ea heathing, cooling absorption,or evaporative cooling sys, incl install of controls regulated by this code. 1MCSUSHTR Commercial Install/Relocate ea M suspended heater,recessed wall htr, or floor mounted unit heater. 1PGASCOM Commerical for ca gas piping System P 1-4 outlets 1BPGAS For each gas piping system of 5 or P more per outlet. 1MCAPPVNT Commercial for the install/relocate/ or M replacement of ea appliance vent installed &not it cl in an appliance permit. 1BSEISMICO Commercial Seismic B 1MRRAA Residential Repair/Alteration/Add to M ea heating appliance,refrigeration unit, cooling unit,abscrption unit,or ea heating,cooling,ebsorption or evaporative cool:ng system,incl installation of controls regulated by this code. 1MRSUSHTR Residential Install/Relocate ea M suspended heater,recessed wall htr, or floor mounted unit heater. 1MRAPPVNT Residential for the install/relocate/or M replacement of e i appliance vent install & not incl in an appl permit. CITY OF CUPERTINO I or FURNA►CE/AC CUPEkTINO FEE SCHEDULE Quantity Fee ID Fee Description. Fee Permit Type Group AIR FURN/AC CONDITIONING 1BCAIRHAN Commercial A/C Units <= 1 O CFM B 1MCRAA Commercial Meca Repair/alt/add M 1BSEISMICO Seismic Commercial B 1PGASCOM Commerical for ea gas piping System P 1-4 outlets 1PGASRES Residential for ea gas piping system P of 1-4 Outlets 1BPGAS For each gas piping system of 5 or P more per outlet. Comm/Resid 1 BREMAIRHAN Residential A/C units <= l Ok CFM B 1MRRAA Residential Mecb Repair/alt/add M 1BSEISMICR Seismic Residential B ' 1EPERMITFEE Electric Permit E 1MPERMITFEE Mechanical Perrrit M 1PPERMITFEE Plumbing Permit P 1TRAVDOC Travel Documeny:ation B 1BUSLIC Business License B Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 MCITY OF Fax(408)777-3333 :UPEkTINO BuildingDe artment JOB ADDRESS: PERMIT # a , s8 4 C��s x'16,.., sj;�- 0 e�o�� OWNER'S NAME: l+ r)7 u rah PHONE # 4,0 - - L J GENERAL CONTRACTOR: v ty vW c FAX # rf ok-• �1 (a-7 2 i I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the followinginformation: SUBCONTRACTOR BUSI14ESS 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 _�7�� - `'`I Owner/Contractor Signa Date