04070077 CITY OF CUPERTINO y% `�_''f " " i' ` '"'�^-
BUILDING DIVISION PERMIT CONTRAC�°TaR INFORMATION
BUILDING ADDRESS: PERMIT NOO 4 0,7 0 0 7 7
OWNER'S NAME: PERMIT ISSUE DATE
BHARAT KRISHNA
NE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION
QC 1 bercby affirm Nat lam licensed under provisions of Chapter 9(commencing Job Description
U
with Section rOfB)of Division Sof NC Busiices and Profvssiona Code,and my he..is
anti InmRfa erre -rl )�1� Cl REPLACE FURNACE & A/C DUCT
^mz DANma a con g.+,+ r
Z�' de Rcx EcrsDEc rloN CONTRACTOR: GOOD FELLOWS A/C HEATING
y P ass all he us, .,.bit. s
,yU o0
3 to na
Liccd Professional
wto as Oat I"m exempt
from
DECLARATION
I hereby.(Sere that 11. .umpt from Ne Genies o e:Anyecense Law for the
p O following rtuoa(Salon 7031.5.Businau and ere.dcsiuu Code:Any easy or county ,
m�+ which requires a permit re eonshueL alcor,impmse,h perroil t ore a sig any shuotum
FZ< poor mitsicrobcd .also require lW applicant for sachpeuier m.signed cot
Nommecing wait pursuant m Ne of Diviouar they,Business
hnd ProclaonsCo(Chip.,9 Sq.Ft.Floor Area Valuat 500
F F G (commencing is exempt
Sectionm and of Division 3 of e aliq eineuand on.Any
Code)of
J!5$ that he is eumpt Ncmfmm and th,buss for the alleged exemption.Any violation of
Section]031.5 by any applicant for a permit hilip to the applicant to a civil penalty of APN Number Occupancy T
not en eve hundred dollar,(S500).
Pane Y YPe
ream N
01,a owner of Ne property,or my employees with wages As their sole compensation, 37533017 . 00
will bu Um work and Jimmmewre is not intended oraRered foraale(Sec.TSU,Buinecs
and Profesdons Code:The Comrscutes Licemse law does not apply in an owner of Required Inspections
progeny who builds or improves thereon,and who does such work himsel f or through his
Own employee,provided that such improvements Are,notimmzided oroRered forsale If,
however,the Wilding or improvement is sold within one year of completion,the owoer-
builder will have the burden of proving Nu he did not Wild or improve for purpose of
talc.). Oat V:(/�j r�
1,u owntt rj the Sec.7 .B uelusiv and
,routing with Ii TheeA oontrattam U. — �1
construct the es not (Sec.Joan
Business and property
who hudns;Code:)droves demon,
nd JUL
cense law dors not apply to an owner of property who W Ills or improves Merton,and a/U 9004
who conhacts for such prole, withacontrubrial licensed pumuant to the Commutes L
nee law.
am exempt under Sec .B&P C for this moon Q
Owner Dam ��s�DING
WORKER' COMPENSATION DECLARATION
1 hemby affirm under penalty of perjury ore of the following declarations:
I haw and will mountain a CeniGate of Commit m self-insure for WorketaCompen-
sation,u provided for by Section 3700 of the Labor Code,for Ua performance of thc
work for which Nis Permit is issued.
❑1 have and will maintain Workers Compensation Insurance,u mquimd by Section
37W of the labor Code.for the performmtt of the work for which Nis permit is issued.
My Workcr's Comte ens ion Inaurence carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EKEMMON FROM WORKERS'
COMPENSATION INSURANCE -
m u section nerd not becomplcmd if the permit is(erase hundmAdolles(SI(Ay)
or Ices.)
I unify Not in Ibe Nrform{yn^ce of the work for which Nix Pcrnit is issued,l shall not
employ any pc in m&ker ssazd Wmmembjed to the Workers Compensation
Lawsof Califorspj ate
MI
lion
A It
it
N E MAP after making this Cenihcate of Exemption,you should
be subject m the Worker's Compensation provisions of the Labor Code,you must
.Jz forthwith comply with such Provisions or Nis Permit shall W deemed revoked.
'Z O CONSTRUCTION LENDING AGENCY
P.�. I hereby affirm that Nem is a conssrocion lending agency Jar the Performance of
the work for which Nu permit u issued(Sec.3097,Civ.C.)
ALemleh Name
]Z Lender's Addrus
[)C) I unify that I have read this application and sate that IW aW ve infotmatiun is
W F corms 1 agree to comply with all city and county oNimmees and state laws relating to
O U building construction,and hereby authorize represenmiva of this city in enter upon the
Y'C above-mentioned PmPerly for inspection purpaca
(We)agree he saw,indemnify and keep hannl,ss Ute City of Cupertino egtlnst �/`�J 1.aC./c./ /
fA
liabilities.judgments.costs and expcnsca which may in any way accrue against said City
U z A APPLICANT
of UNDERSTANDS
of this Permit. Issued by: DBIC
'-` APPLI/OCEANT UNgD/7E�1RSfAN05 AND WILL COMPLY WITH ALL NON-POINT
SCI I%ECUIY Chl . /S 7
Re-roofs
s' nuts tan on for Dan
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant storm or handl,hmatdou material
Or defined by the Cupertino Municipal Code.Chapter 9.12.and the Health And Safety
Code,section 25532(x)? �J
❑Yes AaJNo All roofs shall be inspected prior to any roofing material being installed.
Will IM applicant or forum building occupant use equipment ordcvice which If a roof is installed without first obtaining an inspection,I agree to remove
.mit hamudous air contaminants defined by Nc Bay Arca Air Quality Managcmcnt all new materials for inspection.
District?
Dy.
I have mad the has bdousmamrialsmquircmmis under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25531.1 undcrsurd that i(Ihe Wilding
does riot currently ve a Tenant,Nat it u my tupouibility,m notify the occupant of Ibe
mquirements ieh steemet or
an«onceninamarOcaPan`y' Signature of Applicant Dale
Owner or motion ant Dn,c All roof coverings to be Class"B"or better
r Community Development
10300 Torre Avenue
It Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT #
a v
OWNER'S N j.. PHOtTE #
GENERAL CONTRA R FAX #
I am not using any subcontractors:
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
-Egulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
-7 1yOwner/Contractor Signature Date
CITY OF CUPERTINO
Son FURNACE/AC v �-7 ,,=, o77
UPEITTINO PERMIT APPLICATION FORM
APN #��� Date:
3 3 017
Buil ' d dre
Owner's Nam V Ph e #
d6fffa'cf6r: d
2 Phone: License#: V
Cont � Phone: S3 C ertino us ess License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Descriptio �
U Gc cJ
Residential Commercial
For Residential Installations:
Attic ❑ 1" flo2nd floor❑
dhere to min set back requirement❑
itor Commercial Installations:
eplacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project Type of C nstru on: � Occupancy group:
Strapped ❑ n Platform ❑ 13011ded Sq.Ft. Floor Area:
New Location Replacement ❑
Qty. 'f
A l' Fee ID Fee Description Fee Group
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
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMUTFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BU LI Business License L.1 L I BUILDING
- $ 3;-o' -