03090107 CITY OF CUPEXIINO
BUILDING DIVISION PERMIT CONTRACT0 1, NI+ORMATION "
Bull.DlNC ADDaess: KESTER HEATING AND AIR CON ERMIr N%3090107
OWNER'SNAME: 4351 GLENPARK DR PERMIT ISSUE OATS
3
1NL (408) 265-1103 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Op
LICENSED CONrRACnOR'SDEConsof CON Job Description
Ew❑ I ion 7 affirm that 1 am IVttnseO under provisions of Chapter 9(commencing �! p
iW with Scairn]qxp of Division]arose Business and Professions Code.and my license is ���__._ w®
in full MR�'ymid effect. ,Y
;Ey3j LiecrswZfass 64b0 REPLACE
mudi
m el Dam Cun ErECI_ S �I at
lYY� M" Hlt W irsS IIECLARAL9 y 1 �OO'T
C U I understand my plans shall he used as public rtnntls � 20oO
t' Licensed Professional J
cit OWNER-BUILDER DECLARATION _ _ BUILDING a P I hereby affirm that 1 am exempt from the Contractor's License Law for the me BU • •• 'Y
COO following reason.(Section 703 15,Business and Profess ims Code:Any city or county
m which requires a Permit to construct,alter,improve,demolish.or repair any structum
prior in its issuance.also requires the applicant for such Permit to file a signed statement
that he is licensed pumiumto the previsions of IAC Contractors License Law(Chapter 9 S . F . Floor Area Valuation
e.0 (commoner ng with Section](1(XB of Division J of the Business and Pmfcssions Code)or
$ Nm he is exempt therefrom and the basis for the alleged exemption,Any violation of 2 3 0 2 9 . 0 0
Section 7031.5 by any applicant for a permit subjects the applicant o a civil Penalty of APN Number
not more than five hundred unit...(s500). - - - Occupancy Type
❑ 1,re;owner of the property,or my employees with wages as their sole compensation,
Will do the wort,and the Shuctme is not intended or offered for sale(Sec.7tN4,Business
and Professions Coda:The Coami License Law dors not apply to an owner of C On$
property who builds or improves thereon,and who does such work himself or through his 303 — ROUGH eA�
own employca,provided that such improvements are not intended an offered for sale.If. 3O4 — ROUGH ELECTRICAL
however,the building or improvement is said within one year of completion,the owncr-
builder will ban the burden of proving Nat he did not build or improve for purpose of 5 05 — FINAL ELECTRICAL
salejEll.. 507 — FINAL PLUMBING
1.as owner of the furriery,.m exclusively contracting with licensed contractors i-
come La des not (Sec.]tea,wnerof and Professions Code:)The
vesidoeon. Li-and SOS — FINAL MECHANICAL
chase law docs not apply c an with
a of proper(who sends or ant to
Centro,and
whoU..for such projects with a contra<tor(s)licensed pursuant ro the Contractor's
0
License am law.
Q 1 am exempt under Sec. ,B&P C for this reason
137CM
ner Date
WORKER'S COMPENSATION DECLARATION _
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain.Cenificau of Consent to self-in ime for Worker's Compen-
on,u provided for by Section 37W of the tabor Code,for the performance of the _
rk for Which this permit is issued.
1 bave and will maintain Workers Compensation Insurance,a required by Section
rf NC labor Code.for Ne performance of the work for which this permit is issued.
Workers Co pensation Insurance carrier and Policy number ant'IT: fI) Poli o.:__�Vv ' bI
CERTIFICATE OF EX PTI OM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if tie Permit is for one hundred dollars($100)
Lase)
I coni fy Nat in the performance of the work for which this permit is issued,1 shall not
employ any person in any manor so az m become subject to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you shoo
become subject to the Worker's Cam penss ion pmvisions of the Lebo Code,you mat
D z forthwith comply with such Provisions or this Permit shall he deemed revoked,
Z O CONSTRUCTION LENDING AGENCY
1 barony affirm that there is a couwainn lending agency for thc verrormaoc of
x the work[or which this permit is issued(Sec.109],Ci,C.)
agl 1 lenders Name
Z) z Lenders Address
Q I cenify Nat 1 have read this application and some that the above information is
y F" correct.1 agree to comply with all city and county ordinances and sure laws relating to
D U holding mnsuuction.and hereby iurhorim representatives of this city to enter upon use
shove-ms,judged property for acre monmsea purposes.
OW. (we)agree to save,indemnify and keep harmless the City of Cupertino against
z Iiebilitlu,judgments,e rau and of this eamit. may in any way accrvc against said Ciry
..)z, AIPLI queoco DERSmingof this Permit
^ APPLICANT U DERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
5 REGU ATIONS.
44 -dS-o3 Re-roofs
ignamlc rr Appbc.a, ntraao Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle haiuduus material
La defined by the Cupertino Municipal Code.CAapler 1.12,and the Health and Safety
ode Section 255]2(7)? All roofs shall be inspected prior to an roofing material beim
❑ru [3]Po P P Y g g installed.
Will mea truant or rutum building occupant use a If a roof is installed without first obtaining an inspection,I agree to remove
PP C P a Air Qu of devices which g
it"strict? s air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
istria]
0 Yes OMIT—
I haus read Ne hanrdu amaterials requirements underChapter 6.95 ofthe Califor- ,
nia Health&Safety Cods,Sectua 25505.2553]and 25514.1 understand thotif the building
Jos not currently ham a cram,that it is my responsibility m notify de acupant of the
reyvi u whic asst be met prior m issuance of a Cortifoam of Qcupancy.
9ouncy Signature of Applicant Date
mer ser aulli ri agent Dam All roof coverings to be Class "B"or better
CITY OF CUPERTINO
FURNACE/AC
= CUPERTINO PERMIT APPLICATION FORM
APN#
Building Address:
S J o�l Co
Owner's Name: Phone#:
Contractor: Phone: License#: Z _
I�I.5 1 (fDd-)
Contact: Phone: Cupertino Business License#:
`- 2D DD
i ding' rmit'Info:
Bldt/fiject Plumb ❑ M
Job cription:
Residential Commercial ❑
For Resid tial Installations:
Attic 1" floor ❑ 2nd floor❑
Adhere to min set back requirement E]
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: Occup:t grow
3Z,so -
Strapped ❑ On Platform ❑ Bonded Sq.Ft. Floor ea:
New Location ❑ Replacement
Qty. if
A T a e 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
O PPERMITFEE Plumbing Permit issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business icense BUILDING