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03060186CITY OF CUPER'fINO BUILDING DIVISION PERMIT iCONTRACT,nR�INFORMATION: BUILDING ADDRESS: """"03 0 6 0 18 6 r OWNER'S NAME: PERMIT ISSUE DATE ONE: SANITARY NO. CONTROL NO. ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 �00 LICENSED CONTRACTOR'S DECLARATION i8a I hereby arnmt that 1 am licensed under provisions or Chapter 9 (commencing Job Description s< wire S.lion70( Intel. viaion]of the BU.IoW and Profc.iu. Code. and myliccnm is < L erase Class effect. NEW A/C UNITS jq License Class Contractor DBIC i'SDECr ARCHITECTS DECLARATION i I understand my plena shellWUmJ as public mcnrtlx i U Ms � � Licensed Pofessianal OWNER - BUILDER DECLARATION �<i 1 Wmhy affirm that I am exempt from the Contractors License Law per the :0 o following reason. (Section 7031.5, Business and Poressio. Code: Any city nr county $ which requires a permit to construct, alter, improve, demolish, or repair any stnclum prior hr its issuance, also requires the applicant for such Permit to file a signed statement r —< that he is liced pursuant to the provisions of the Contractors Limnse Law Sq. Ft. Floor Area Valuation cm 0 (commencing with Section 7") of Division 3 oflhe Business and Pridommna Code) or 1 that he is exempt therefrom and the basis for the alleged exemption. Any violation of 36921046.00 Seniors 7011.5 by arty applicant for a permit subjects the Applicant to civil penalty of APN Number Occupancy Type nut more Nan B. hundred dollar, (SSW). L u owner of the pommy, or my employee with wages. mob sore compe.adon, will do the work, and tha.me,me is not intended or offered foraale(Sec. 7044, Business 3 — and Professions Code: The Conuacleri License law it. not apply to an owner of 3 04 - ROUGH ECTRI AL ns property who builds or improve thereon, and whodoaasuchwmk himself orthrough his own employees. provided that such improvements arrant intended oroffered for.le. IL 505 — FINAL ELECTRICAL however. the building or Improvement is sold within an ye. of completion, the owner builder wiff have the burden of moving that he did not Wild ar impow for purport of 508 - FINAL MECHANICAL tau.). u owner of the propeny, am exd.ively Contracting with licensed emaracton to rte met the project (Sec. 7014, Basin. and Professions Cade:) The Cmumucto's Li. rue law does not apply to in owner of property who Wilds or improves demon, and who contracts for such projects with a contractor(s) licemed punuam In the Contractors Lieenm IaW. ❑ 1 son exempt under See. , B & P C for this meson owner Data WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury arc of the following deelantions: 1 have and will maintain s CeniBcne of Content b solid... for Worker's COmpcm aion, . provided for by Section 37W of the labor Code, for the performance of the work for which this permit is issued. ❑ 1 haw and will maintain Worker's Compensation Insurance.. mquiod by Section s 3700 of the labor Code, for the pcdormance of dm work for which this permit is issued. My Workers Compensation Insurance carrier and Polity number arc: Carrier: Policy No.: .� CERTIFICATE OF EXEMPTION FROM WORKERS' / v COMPENSATION INSURANCE (Thu section need not hecomplemd if the Permit Is fmane hundred dollars ($100) or less.) e certify that In the Performance any roomer the work for which Nis permit is issued. I shall not [t4 employ any peron in any mnner sec az to become subjecua tW Workers' Compcnution laws of California. Dent Applicant NOTICE hi APPLICANT: r' after making this visi n.m of Exemption, you thrust becomehcompto tic Worh ro Coosorthis provisionso ithe read Code,you must `L roMwuh comply with SUCK Prnvisipv or Nis permit shall be deemed rcwked. O CONSTRUCTION LENDING AGENCY `� —y'v J .y. I hereby Affirm that there lu connmctien lending Agent' ter the Performance of r � the work for which this permit is issued (See. 3097. Cm C.) QLender's Name a. z Lender's Address ) Q 1 certify that I have read this application and .tsm that the Allow information is L f~ correct. I agree to comply with all city and county ordinatmes and sure laws h Wing to U Wilding convection. and hereby aoNorom repmsenulive of this city to enter upon Om y U ahovamentiuned property for inspection pugwses. (We) agree to save, indemnify and keep harmless the City of Cupertino against W liabilities, judgments, costs and expenses which may in any way seem against mid City ),7a, in consequence of the granting of rmit. APPLICANT UNDERSTA S A WILL COMPLY WITH ALL NON -POINT Issued by: Date OURCE REGULATIOISS. I/ Re -roofs T 3 nature of ApplicaHAZARDO Data HAZARDOUS MATERIALS DISCLOSURE Type of Roof ((i / \i% ✓i/ —� Will the applicant or future building occupant store or handle h.un aus material . denned by the Cupertino Municipal Coca. Chapter 9.11, and the Hearth and Safety ode. SAW. 15531(.)7 All roofs shall be inspected prior to any roofing material being installed. ❑Y. ❑Nu Will me applicant or future building occupant um equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove it hanedous air conmminanis u aRfmcd by the Bay Area Air Quality Management all new materials for Inspection: utric6 ❑Yes C) No I have mad the h.artloes materials requirements under Chapter 6.95 of the Califon ntsNealth &Safety Cotle. Sec' 5.25333 a upu12554ty lmdcrsmd thuifm Wilding does not currently have in Amy the occupant of the mquircmcnts which must met ptigr i. an cc or a certificate of Occupancy. Signature of Applicant Date owner or aumorive<gent Dam All roof coverings to be Class "B" or better r 0 6 t I ar, CUPE(,TINO CITY OF CUPERTINO FURNACE /AC PERMIT APPLICATION FORM �.4 APN # Date: Building Address: BUILDING '1 7 G 7 Id ��11.0-rs 1C Irk,/ BREMFURN Owner's Name: Phone #: (44)'1-7-7- G9 I2 Contractor: Phone: Z A License #: s T Aff 'Al BREMAIRHAN Contact: Phone: Cupertino Business License #: �, -'z 7799,1 z- BREMRECEPT Building Permit Info: ELECTRICAL Bldg ❑ EI ct Plum Mech UK, Job Description: BUILDING EPERMT'FEE Residenti Commercial ❑ For Re idential In�a Ilations: Mech Permit Issuance Attic if I" floor U 2nd floor ❑ Adhere to min set back requirement[] Plumbing Permit Issue For Commercial Installations: Replacement same weight ❑ Additional weight (structural calcs) ❑ Bldg Permit Fees Structural Calculations required for new installation ❑ New installation Planning Approv& equired ❑ Plan Check Fee Cost of Proje D e of Constructi n� Occupancy gfoutif BUSLIC Business License Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area: New Location rx Replacement ❑ Qty. if ADnlfeable Fee ID Fee Description Fee Group * 13 ?. 6 0 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 EPERMT'FEE Elec Permit Issuance ELECTRICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMFTFEE Plumbing Permit Issue PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPLANCHK Plan Check Fee BUILDING BUSLIC Business License BUILDING * 13 ?. 6 0