03070078 a CITY OF CUPERTINO y�r "
BUILDING DIVISION PERMIT a�Q T141�TV/R L�,a'�A��,�TION '
BU ILDINGADDRESS: PERMTr NG03070078
'S NAME: LIQ;AP GT- PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
I
CHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
30 LICENSED CONTRACTOR'S DECLARATION Job Description
td u1 hereby affirm that 1 am licensed ands,provisions o(Chaptar 9(commencing p
mmh Section 70ta)of Division Sof Ne Business and Professions Code.and my license is
.."fd=eandoff SLE®
elf CLsaQ�Z,,cuoirecm, '�'-3 FURNACE & ADD A/C .L-'�RAsa�
££ Dem_g ARCHITECTSDECLAR'IT CONTRACTOR: ABC COOLING & H
�C I understand my plans shall M used u public AUG 2 ;82003
)yu
5Q� Licensed Pnafessiomal
OWNER-BUILDER DECLARATION
<X 1 hereby affirm that I am exempt from the Contractor's License Law for the M �'L0 p>♦'DINR'�
following mason.(Section 7031.5,Business and Indications Code:Any city or County which requires a permit to construct,alter,improve,demolish,or repair any structure -
u=j, poor to im issuence,alsu requires the applicant fmsuch pennitao flea signed stamment
S6 that he is licensed Pursuant it)the provisions ofthe Connector's License Law(Chapter 9 Sq. Ft. Floor Area Valuatrroy1188
el-0 (commencing with Section 7")of Division 3 or the B attracts and Pro(cmions Cook)or
.-
that he Is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of 38211U0eter00 Occupancy Type
not more than five hundred dollars(S500).
D 1,as owner of the prepeny,or my employees with wages u their Onto compensation.
will do the work,and the structure is not intended or offered for sale(See.70,14,Business Requ�lred Inspections
end Profeasiona Code:The Crawler's License Law ems not apply=an owner of 3 01 - ROUGH PLUMBING
property who builds or improves Bummer,and who does such work himself or through his
own employees,provided that such improvements trent intended oroffered formic.If, 303 — ROUGH MECHANICAL
however,the building or improvement is sold within one year of completion,the owner.
builder will have due burden of proving that he did not build or improve for paryote of 304 - ROUGH ELECTRICAL
tale.).
D1.as owner of the property,am exclusively convecting with licensed contractors to 505 - FINAL ELECTRICAL
consumer the project(Sec.7044.Business and Professions Code:)The Convector's Li. 507 - FINAL PLUMBING
cause taw does not apply to an Owner of Property who builds or improves themon,and 508 — FINAL MECHANI CAL
who contracts for such projects with a convactods)licensed pursuant to Ne Contractors
License Law.
❑I am exmmpt under Sec. .B&P C for this reason
Owner Data
WORKER'S COMPENSATION OECI RATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Content to self-insure for Worker's COmpcn.
mtimn,u provided for by Section 3]00 0(U=4bor Code,for the performance of the
w rk for which this permit is issued.
have and will maintain Workers Compensation Insurance,m required by Section
700 or the labor Cade,for the performance of the work for which this permit is lured.
My Worrk�k++er's Compensation Immmnce carder and Policy number a-ma: 1/'
CarierJ• 'T 1— C91— policy No� ��-aJ� 97-��
CERTIFICATE OF EXEMPTION FA MWORKERS'
COMPENSATION INSURANCE
(This section recd not be completed NOW pomtit is foram hundred dollars(SI011)
tor Mss.)
1 certify that in the Performance of the work for which this permit is rotund.l shell not
employ any person in any manner m u in become subject to the Workers'ComPemation
Law.Of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions Of the labor Code,you must
O forthwith comply with such provisions or this permit shall be deemed revoked.
,ZaiCONSTRUCTION LENDING AGENCY
I hereby affirm Nat there is a construction lending agency for the performance of -
C'i the work for which this permit is issued(gee.3097,Civ.C)
W�Q Lenders Name
7. Lender's Address
U 1 certify that I have rend this applicNon and sues that the above information is
Da F correct,I agree m comply with all city and county ordinances and sum taws relating Id
�U building construction,and hereby authorize representatives of this city to enter upon one
W above-mentioned property for impaction purpose. �'
(We)agree to save,indemnify and keep harmless the City of Cupertino against
gy h liabilities,judgmenu,costs and expense which may in any way accrue against mid City
U rZ.a inconsequence
of the UNDERSTANOranting fthispe,WILL COMPLY WITH ALL ON-POINT Issued by: Date
SOURCE REGULATIO
L /V Re-roofs
Signature of ApplicanVConuacmr Dam
HAZARDOUS 4ATERIALS DISCLOSURE Type of Roof
Will rhe appticmi ser future building Oceupanutorc or handle havArdou material
u dcf=ed by Lha Cupertino Municipal Cade,Chapter 9.12,and the Hcalth end Safety
ale,Section 25532(a)?
Yea 6+0-- All roofs shall be inspected prior to any roofing material being installed.
e
Will the applicant or future building Occupant am equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it Marietta it contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
Into
trict?
Dyes ptma-
1 have read the lusardnus mamrialemquimmcnts under Chapmr6.95 of the Calif.,
Health&SafmyCodc,Sccdou 25505.25533 end 25534.1 understand that i(Pe building
s not currently hese a meant,that Ir is my mnamsihiliry m noltly the rcupart of Ne
uimmcn whip cert Prior m' umce a a Cadwale ojllc Panty. Signature of Applicant Date
��
Owner Or eulhdri'red o
nl am All roof coverings to be Class "B"or better
'
CITY OF CUPERTINO 7 79
FURNACE/AC
OF
CUPERTINO PERMIT APPLICATION FORM
APN# / 0— D Date:
Building Address: Ae-,Z�
Owner's N e: G Phone#:
• 2s2 -5910
Contract C Phone: License#:
((�a 4 S'/o Z/ 38"23 813
Contact: hone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect Plumb Mech 114
b D sgri tion: 3 3
a.0.- �. boa 0tv U - 4 3 Qn �`Q
Residential Commercial ❑
For Regs�idential I Mations:
Attic LJ 181 floor 2nd floor❑
• Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation El
New installation Planning Approval Required
Cost of Project: Type of Construction: Occupancy group:
WST. 6'0
Strapped LJ On Platform 11 Bonded 0 Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
AppliosWe 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
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING