05100001 CITY OF CUPEWFINO •-ap'c , .L,
BUILDING DIVISION PERMIT �,CONTRACT IQR INFORMATION ,
BUILDING ADDRESS: PERMIT NO.0 510 0 0 01
807 BETLIN AV
OWNER'S NAME: PERMIT LSSUE DATE
RAMCHANDRA NADKARNI 10/03/2005
NE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT.. PLUMB - MECH
0 0 0 0
uoa LICENSED CONTRACTOR'S DECLARATION lob Description
4w 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing p
Z� with Section?IXl01)Of Division SoftW Business and Professions Cme.and m�license is .�
n<n
in(Or
�,�„24cIy RELOCATE FURNACE/EXTEND GASy,'PIPB�
License Class Lie.N y�iEn
C�, Dam courmic CONTRACTOR: KYM MECHANICAL j '}�t
'perp A HITECI'S DECLARATION
C< I understand my plans shall he used u public records ^ Z
"H Licensed Professional P^T jS �nn5
OWNER-BUILDER DECLARATION
<f1 bunchy atT,m shot I am exempt from the C....ctm's License Law far the
O o follawin 9 ses rc.mm.Ui,n tid n 7031.5,Business and Profemintu Code:Any City
r county
which in via pt to eun druct,eller,ou y,demolish,of ru air an stmt(.. >ti
_Zr prior tofu issuance.also Moneta the applicant for such permit to rile a signed smtcrecnt w;y. taygg ,
< thinM is licensed puromma to the Provisions of the COnumcwh License Law(Charter 9 Sq.Ft. Floor Area aKiWfi$61300
,HS (commencing with Section 7fOff M Division 3 of the B traumas and Professions Code)Or
y _ that he is exempt tMmfram and the thou for on,alleged exemption.Any violation of
Section 9031.5 by any applicant for a permit svbpmU the applicant o a civil penalty of APN Number Occupancy Type
ant in..than five hundred dollar,(Ss6o). 36927017 . 0 0
❑I.as owner of the property,or my eroployce,with.,a u dinum,le compensation,
will do the work,and the swenim is not intended m.ffemd(orale(Sec.]0104,Business
and Professions code:The Contracwrs License law dose Out apply b.n owner of Required Inspections
prop0ny who builds.,improves thereon,and who does such.,it himself ser(.rough his
own employca,provided that such improvements ve not intended or offered forsade.If.
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving Nat he did not Wild or improve for purpose of
u[e.).
1,as owner of the property.am exclusively contracting with licensed containers to
conswct the project(See.9644.Business and Profusions Code:)The Contractors Li.
coat taw docs not apply to an owner of progeny who Wilds or improves themon,and
who contracts(or such pmjetts with a eomnctor(s)licensed pursuant in the Conv.eto's
License law.
❑ L am emmpt our Sec. .B At P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
l hereby affirm under penalty of perjury one of the following declinations:
I hay and will maintain a Cee fieme of Consent o self-insum for Workers Compete
tion,u provided for by Section 3100 of the labor Code.far she parformance of the
work for which this pcmnit is issued.
❑I have and will maintain Worker's Compensation Insu ..u myuimd by Section
3900 of dm labor Code,for the performance of the work for which this permit is issued.
My Work"' C�nm/p�e r�aI nn Insurance carrier and Policy numberam
Cartier- t r'1 t a.. W fs't�G]N'f hry Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleted if the r nmit is formic hundmd dollars(S I W)
ser less)
I cenify that in the pefformanec of the work for which this permit is issued.I shall not _
employ any person in any manner so as an become subject to the Workeri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this CLnificale of Exemption,you should
become subject re the Workers Compensation provisions of the Labor Code.you must
.J O foMwith comply with Such provisions or Nis permit shall he deemed invoked.
'Z CONSTRUCTION LENDING AGENCY
{� l hereby affirm that Nets is a conalovinun[ending agency for the performance of
a thL work for which this pwmit u issued(Sec.3097,Civ.C.)
tg1 Lenders Name
U Z Lender's Addmss
U Q I comfy ee Nat I hay,cad this application and state that the SWy inlOnOuntinMining Is
ly UWareing I agree m comply with all city and county ordinances and sum laws ranting m
V Wilding ivrs of thin city to enter upon the
(—' y cajud gme m say,indemnify et keep harmless the City of against
against
Habillin inconsequenc of dic granting of
earponsof thisesmit, may in aY way accrue,gains said City
V z A APPLICANT
NDERanting of this permit.
^' APPLICANT UNDERST NOS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale /0^7-pj;�"
SOURCE REG ULAT I
`� �10` Re-roofs
fhC_
Signature of plican L7CMMTc,.r I Dat -
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant stow or handle harsNous material
as defined by Ne Cupertino Municipal Code.Chapter 9.12.ad the Huhn and Safety
ale.Section 255321x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yw �No
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
strict?
Yes L
I have read the havardousmaterialsmyuimmenu under Chapwr6.95 of the Calirof-
7isni,
Health&SafetyCoce,Sections 25505.25533 and 25534.1uM Nndersumthe i( Wilding
es Our currently haw s tenac that it is my respmuibility 10 notify thL occupant of mL
vircmenuw - st sect prionnissuancc ora Cenihnteof Occa acg Signature of Applicant Date
ow u on, agent ` ate All roof coverings to be Class 'B"or better
�:. Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY 0, Fax(408) 777-3333
SUPE(�TINO
Building Department
JOB ADDRESS: PERMIT #
go I3cTL► t�j Ave 0ST`6 0C�0/
OWNER'S NAME: R M O-t M+ MA N A'b V AItMi PHONE # 09j 4!k 6 -`qV j?
GENERAL CONTRACTOR: +GA1 FAX #
I am not using any subcontractors:
e 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
` CITY OF CUPERTINO
FURNACE/AC
OF
�CUPERTINO PERMIT APPLICATION FORM
APN # Date:.
Building Address:
Owner's Name: �� G Phone #:
1p, 1�zA N a az ,.h C2io V I 9(o/- 4 51 Y8
Contractor: l M _ License#:
Contact: i ' Cupertino Business License #:
��4'nW��� ��t � Y { y
Building Permit Info: PkZ n `/ Kj G AC-f C��AI Gr�
Bldg El Elect D Plumb ❑ Mech ❑ P PZ �6'
Job Description: AF PC&%,
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1" floors 2nd floor❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Plannin A ,oval Re uired ❑
Cost of Project:300 Type of Construction: Occupancy group:
Strapped ❑ On Platfon"' Bonded ❑ Sq.Ft. Floor Area:
New Location Replacement ❑
Qty. if
A licable Fee ID Fee Description Fee Grou
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit > 1Q000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfrn MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
EPERMITFEE Elec Permit Issuance ELECTRICAL
l MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
�- BUSLIC Business License BUILDING
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