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• CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
CONTRACTOR INFORM-WTION
BUILDINGADDRESS:
A &a H HEATING
PERMIT NO 04010085
OWNER'S NAME:
PERMIT ISSUE DATE
R
ONE:
SANITARY NO. CONTROL NO.
CHITECT /ENGINEER:
BUILDING PERMITINPO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
9
IOh Description
I Whby affirm that I am licensed under and Pr9ons of Chapter (commencing
With Section ]Qll}I)uf Division 7of NC Business and Pr cs$ion COdc. antlmyliccnm is
in full fnteeaa(vd"crtee ,/gf
License force
s Lie. a " '3
REPLACE FURNACE I�"IWpF9`rm®
Dam C.. ..'m N
�.�`EE
C ARCHITECTS DELL N
I understand my plans shall bo used as public Mods
FEB 1 6 2004
Licensed Pmfwimind
OWNER - BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
followings n.(Section 7(n IS. Business and Profwiom Cale: Any city or county
P
BUILDING
which requires a Permit to construct. nlmG improve, dcmneish, m repair any structure
prior to its issuance. also requires the applicant for such permit m file a signed statement
that he is licensed pursuant to the pmvisiout of the comractor's License Law (Chapter 9
Sq. Ft. Floor Area Valuation
(commencing with Section 10BB) of Division 3 of the Businesx and Phfessions Code) or
that he is esempt therefrom and Nc hues for the alleged exemption. Any violation of
Section 7031.5 by any applicant for. permitsubjccts NC spilicanuo a civil penalty of
3ATN5'b"er00
OCCU anC -Type
not more than five hundred dollars ($50%.
P Y YP
❑ Luownerof the pestruc remycmploycuwithwagesuNei(sole compensation,
will do the work and e: The turcis not intendede aw do faroakpply oDan Business
and Code: The Contactor's Law doe, not apply lf an owner or
.Required Inspections
nywhonm
who and
and who such Work himself nd though Af.
owneny
s, proaded that such
ownemployees,provided sum not
bimprovements arcnot intended or for sale. If.
leered
pr vi
builder the orimphsmenlissold Within one year of completion, the owner,
.
have
builder will have the burden of proving that W did not build or improve for purpose of
sale.).
❑ I, as owner of the propcny, am exclusively contracting with licensed contractors to
consumer the pmjccl (Sec. 70a4, Business and Prefnsalons Code:) The Contractor's Li.
come law does Out ply to an owner fp ,.,,,, who Wilds or improves thereon . and
who contracts for such projects with a contracmKq licensed pursuant to d ¢Contractor's
License law.
.
❑ 1 am esempt under Sec. B & P C for this mason
Owner Date
WORKERS COMPENSATION -DECLARATION
1 hereby aRtm under penalty of perjury one of the following declarations:
.1 has and will maintain a Cenificau of Consent to self - inure for Worker's Comfort-
n, as provided for by Section 3700 of dte labor Code, for the peelmormo a of the
for which this permit is Laved.
I have and will maintain Workers Compematimn Insurance, u RyYimd by Section
1700 of the labor Code, for the performance of the work for which this permit is issued.
'
My WOrkcri Cnmpcnsautun lnstuantt carticr and Policy nu be
Cartier. •L Policy i/.(�
'
CERnFIC S NOM R'ORKERS'
OMPE
COMPENSATION I
pDMPEN$ATIDN INSURANCE
(Thimfection need trot he completed it ter permit is for tune huMted dollars (SIM)
nr less.)
1 certify that in the performance of the work for which this permit is issued. 1 shall not
employ any proton in any manner an as to become subject to tW Workers' Compensation
lawa tuf California, Date
Applicant
NOTICE TO APPLICANT: IL after making this Cenifrcate of Exemption, you should
become subject to the Worker's Camperaation previsions of the labor Code, you muu
foMwith comply with such previsions or this Permits all W deemed revoked.
CONSTRUCTION LENDING AGENCY
I Imrehy aRrm that them is a construction lending agency for dte Performance of
the work fur which this permit H issued (Sec. 3097. Civ. C.1
Under, Name
Lender's Addrw
1 cenify that 1 has read Nis application and state Nat the aWm information is
runner, l agree to comply with all city and county ordinances and more laws heating to
'
Wilding construction, and hereby airdrome representatives of this city to enter upon the
shovesc4rxuned pronisuly inspecdontrit, a
(We) agree to sam indemnify and keep hantdcu the City of Cupertino against
Iiabilitics,judgmcnts, costs and expenses which may in any way accrue against mid City
��
the
I. conseyucnce of Nc granting of this Permit.
Sombin
APPLICAV UNDERSTANDS AND W COMPLY WITH AL NON -POINT
S� E ULATIONS. , "7(�_
C4 � �!/
Issued by: Date
(
Re -roofs
Signature of AppUmon/Conmcmr pale
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building Occupant stare or handle hammdous material
u defined by the Cupenino Municipal Code. Chapter 9.12, and thc Health and Safety
CWC. SC Yes 2353Ha)?
❑rea p7�'
All roofs shall be inspected prior to an roofing material being
P p y g g installed.
Will Nc applicant or future Wilding ottupam trsc equipment or Jcvitts which.
If a roof is installed without first obtaining an inspection, I agree to remove
g P
it hmardous id, conamimmis u droned by the Bay Arc. Air Quality Management
all new materials for inspection.
mocty
❑Yes
1 have had the hvuNwsmak:rials equionenta under Ch.punii.95 of the Califnr-
ilia Health & Safmy Code, sections 25A15. 25533 and 25534.1 understand this ifthe Wilding
does wt curmmly has a tenant Nat i is my rmponsihility to notify the occupant the
myul en whichmus,ZZIin uanc ii Crouseeor r
Signature of Applicant Date
All roof coverings to be Class "B" or better
owner err aatbo(ized agent pare
CITY OF
�CUPERTINO
CITY OF CUPERTINO
FURNACE /AC 00095
PERMIT APPLICATION FORM
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APN # s I D p�
Date:
BENERGY
Building Address
J AL
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BU[LIDNG
Owner's Name: m r
Phone #: -q WS - --
Relocation of Furnace
Conaactor: &i to �
Aq 14 4A
License #:30(fY -7A.
Contact:
( � RfEpS
Phone #:
.279-07,1,;L. -- —
Applicant /Contractor: Al
A/C Unit > 10,000 cfm
Building Permit lnfo:
Bldg Elect - - -- Plumb -- mec
Job Description: t
Residential:
A/C Units <= 10, 000 cfm
(� Commercial:
Sy.Ft. Floor .Area:
Rec tl, Switch & Outlets
Architect/Engineer:
Valuation:
Type of Construction:
Occupancy Grow r
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Fee Tn
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BENERGY
Eger
TL " IP
BU[LIDNG
BREMFURN
Relocation of Furnace
MECHANICAL
BREMACOVER
A/C Unit > 10,000 cfm
MECIi.ANTICAL
BREMAIRHAN
A/C Units <= 10, 000 cfm
MECHANICAL
BREMRECEPT
Rec tl, Switch & Outlets
ELECTRICAL
BSEISMICRE
Seismic Fee Res
B fLU IDNG
EPE P,MITF E
MPERMITFEE
PPERMITFEE
Elec Permit Issuance
IvIech Permit Issuance
Plumbing Permit Issue
ELECTRICAL
D4ECH.ANICAL
PLUMBING
BPERMFEE
BPLANCHK
Bld,(> Permit Fees
Plan Check Fee
13UILIDNIG
BUILIDNG
BUSLIC
Business License
BUIL BIN G
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