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05010148 CI'T'Y OF CUPERTINO = BUILDING DIVISION PERMIT CACTONTRjNk'O,RMATION ,,' " BU WILDING ADDRESS: I'IAYEDE NIUFAR PERMIT N905010148 DNERISSU 'SNAME: PERMIT E DATE ONE: SANITARY NO. CONTROL N0. ARCHY ECfIENGINEER: BUILDING PERMIT INFO BLDG ELECT' PLUMB MECH I� 0 +oo LICENSED CONTRACTOR'S DECLARATION' ve I hereby affirm that 1 am llcenacd under provisions of Chapter 9(commencing Job Description It,Section 7031)of Division 3 of the Buainess and Professions Code,and my license is m(vu force and arrear' NEW FURNACE j�K Lleense Class Lie.p F o Datc Contractor CCpp AR CHITECTS DECLARATION C a'u IuntlJ m erslany plans shalM I used as public records '0 Licanzed Professional g OWNER-BUILDER DECLARATION a P 1 hereby affirm that I am exempt from me Contractors hittnse Law for the p O fullnwing reason.(Section 7331.5,Business and Pntfexsions Code:Any oil,nr county <m which requires a pctmit to construct,alter,improve,demolish,or repair any structure poor o its issuance.also requires the applicant for such permitm rile asigned.nammnt 7rat that he is liecnsed pursuant to the provisions(if the Contractor'a License aw(Chapter 9 Sq.Ft. Floor Area Valuation 2F� (eommencing with Section 70(10)of Division of the B uslneas and Professions Coac)or NR that he is exempt them and the basis for the alleged exemption,Any vi ltaion of Section 7031.5 by any applicant for a permit subjects me applicant to a civil penalty Of 3'hIPN'dm13�er0 0 QC U anC not more man Five hundred dollars(S500). P Y Type 1.im owner of the property,or my employees with wages a5 their sole compensation, will do the work,and the swcture is not intended or offered for sale(Sec.7D4,1,Bust nus and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections properly who huilds m improves thereon,and who does such work himself or Through his own employees,provided thxlsuch improvements are notinumded oro3ered Rated,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 . talc.). ❑ 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" cionam law docs not apply to an owner of progeny who builds or improves thereon,and who contracts for such projects with a catuactor(s)licensed pursuant to the Contractor's Laramie Law. _Ca 1 am exempt under Sec. .B&Per' In moon Owner/1"t Dam 11VORKER'S COMPENS TIO DECLARATION thereby. mar nderpenallyor'd im of me following declarations: 1 have and will maintain a Certificate of Consent to self-insum for worker's Comport- 1[3703 ion,a provided for by Section 3700 of the Labor Code,for me performance of the work for which m15 perttlll is ISSY[d. I have and will maintain Worker's Compensation Insurance,u required by Section of me Labor Code.for me performance of the work for which this permit is issued. y Worke's Compensation Insurance carrier and Policy number am: mer, Policy No.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE mm;section need not be completed if the Permit is fmonc hundred dollars(5100) or less.) 1 certify mat in the perfnmmnee of the work for which this permit is hemed,I shall net employany to ymannerasoasmbec beat tot Wmkers'C Compensation Lawsof CT�II a.Dye Applican 44 441 NOTICE TO APPLIC NT:If,after making This CertificateEae prion,you should became subject to the Worker's Compensation provisions of thc r Code,you must Oforthwith comply with such provisions or this permitshall be deemed revoked. Z f� CONSTRUCTION LENDING AGENCY I herby which his mea mere is s ed(Suerinn lending agency Inn the perfurmancc of 4 7 the work for which rets permit is issued(Sec.3(Y37,Civ.C.) DQ Lendefs Name �+ Unit 's Address a J ti1 ecnify that I have read this application and sum that me above information is (•" correct.1 agree To comply with all city and coumy ordinances and sure laws relating In 7V building conswclion,and hereby authorim representatives of this city to emaripon the ���� W ahovcmemtunc0 property for iupenion purposes. y (Wc)agree to save,indemnify and keep harmless the Ciry of Cupcnine against /-2-1 N Iiabililics,judgmenixeciB and expenses which may in anyway accrue against said City ;)Z in emote rence of the granting atr this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALLON-P INT Issued by: Date SOUR EREGULATIONS. 'I—ya�o �f Re-roofs O Signaw fAppli anVCommoor Date 07 HAZARDOUS MATERIALS DIS OS E Type of Roof Will me applicant or ruwm building eacupant store andle hazardous material as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safely Code.Section 25532(a)? All roofs shall be inspected prior to an roofing material beim ❑res ❑Na P P Y g g installed. Will the applicant or future building occupant use equipment or devices whim If a roof is installed without first obtaining an inspection;I agree to remove preen til haiamnus air contaminants a defined by me Bay Arca Air Quality Management all new materials for inspection. t IYlllCl? - ❑res 0 N I have read the hazardous materials mquircmenu under Chapter 6.95 or the Califor, this Health&Safety Code,Secbom 25505,25533 it 25534.1 eadcomod that if he building docs not currently haw a mora that it is my respovibilily m notify die occurrent of the requtremnt.5whichromatain nmtuia cosec 'actor spany. ignature of Applicant Date owner atr r.d a am I �� All roof coverings to be Class "B" or better Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY Of Fax(408)777-3333 �UPERTINO Building De artment JOB ADDRESS: p PERMIT # OWNER'S NAME: PHONE # GENERAL CONTRACTOR: FAX #n , I am not using any subcontractorst 02�Vin, l /V f o2� Q1� Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS 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 Owner/Contractor Signature Date OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate family (parent,spouse or child) will perform A. All the work authorized by this permit B. A portion of the work C. _ None of the work If B or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hired to do: A. _ All of the work B. A portion of the work (complete section below) Contractor Address/City Phone # State License # Type of work to ilr 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City Phone Number Type of work to be _performed ..................................................................................................................................................................................... I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner-Builder Information (reverse side). Property Owner's Signature: Date: I a Job Address: 1 X11 ���• a ._ v Permit# Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. City'of Cupertino Building Department CITY OF 10300 Torre Ayenu C'wI P E[?T I N O Phone: (408)777-3 Dear Property Owner. An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should be aware that as owner-builder you are the responsible party of record on such a permit Building permits are not required to be signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself,you may urotect vourself from possible liability if that person applies for the proper permit in his or her name. i Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the city or county. They are also required by law to put their license number on all permits for which they apply. If you plan to do your own work,with the exception of various trades that you plan to subcontract,you should be aware of the following information for your benefit and protection If you employ or otherwise engage any persons other than your immediate family, and the work (including materials and other costs) is$200 or more for the entire project, and such persons are not licensed as contractors or subcontractors, then you may be an employer. If you are an employer,you must register with the state and federal government as an employer and you are subject to several obligations including state and federal income tax withholding,federal social security taxes,workers compensation insurance,disability insurance costs,and unemployment compensatioio contributions. There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with respect to workers' compensation insurance. For more specific information about your obligations under federal law,contact the Internal Revenue Service (and,if you wish,the U.S. Small Business Administration). For more specific information about your obligations under state law,contact the Department of Benefit Payments and the Division of Industrial Accidents. If the structure is intended for sale,property owners who are not licensed contractors are allowed to perform their work personally or through their own employees,without a licensed contractor or subcontractor,only under limited conditions. A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder building permit,erroneously implying that the property owner is providing his or her own labor and material personally. Building permits are not required to be signed by property owners unless they are performing their own work personally. I ` Information about licensed contractors may be obtained by contacting the Contractors State License Board in your community or at 1020 N Street,Sacramento,California 95814. Please complete and return the enclosed owner-builder verification form so that we can confirm that you are aware of these matters. The building permit will not be issued until the verification is returned. Very truly yours, Building Department, City of Cupertino Printed on Fecycted Paper r i I . Community Development SFr"' 10300 Torre Avenue Cupertino CA 95014 :may Telephone(408) 777-3228 CITY Of Fax(408) 777-3333 �UPEt�TINO Building De artment I, f , JOB ADDRESS: � t,� PERMIT # I rEc�,U_�s . OWNER'S NAME: ! ` I / v<'c Ict t� PHONE # GENERAL CONTRACTOR: L FAX # _.{ r r ; Inc _7 I am not using,any subcontractors: S2 _ Signature Date Please check applicable subcontractors and complete the following ' ormation: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excayation Fencing Flooring: Carpeting Linoleum/ Wood Glass / Glazing Heating Insulation Landscaping Lathing- Masonry athin —I g Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date i CITY OF CUPERTINO FURNACE/AC os 61 uPErZTINO PERMIT APPLICATION FORM APN # v 37h Date:� I Building Address: 19 /�^ v 6 - Owner's Name: Phone #: Contractor: Pho : en Contact: Phone: - Cupertino Business License Building Permit Info: —/ �/ _ Bldg ❑ Elect �d Plumb �d - Mech t2/ - Job Description: Residential Commercial ❑ For Residential Installations: Attic -E, 1�t floor ❑ 2nd floor❑ - dhere to min set back 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: , Type of Construction: -Occupancy group: - Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area: New Location ❑ Replacement ❑ Qty. if Applicable Fee ID Fee Description Fee Group BENERGY Energy BUILDING BREMFURN Relocation of Furnace MECHANICAL BREMACOVER A/C Unit> 10,000 cfin MECHANICAL BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL BSEISMICRE Seismic Fee Res BUILDING' BSEISMICOM Seismic Commercial BUILIDNG EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMITFEE Mech Permit Issuance MECHANICAL / PPERMITFEE Plumbing Permit Issue PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPLANCHK Plan Check Fee 2VBUILDING BUSLIC Business License - BUILDING