05030099 CITY OF CUPEWrINO sv»,Assa l
BUILDING DIVISION PERMIT � �_ NFwO?%ri RMATI3Os�^.
N -i
BUILDING ADDRESS: PERMff NO.
05030099
OW NER'S NAME: PERMIT ISSUE DATE
12 qW
.ONE: SANITARY OL NO.
ARCHITECT(ENGiNEER: BUILDING PERMIT INFO .
BLDG ELECT PLUMB MECH
uo0 LICENSED CONTRACTOR'S DECLARATION Job Description
m❑ 1 hereby affirm Out 1 am Iicenmd under provisions or Chapter 9(commencing p
<W with Section 700(oof Division 3 of the Business and Professions Code.and my license is
^O,^ in full forte and ftt C—
�q: License Clara _011,4A UC.Y �5_ INSTALL HEATING & A/C
aDOc conuaclnrG.F�o,e cO ate CONTRACTOR: APEX/CI HEATING AND A/C
t !p ao: ARCHITECI'S DECLARATION
z< I understand my plans shall bC and as public records
�aU
o Licensed Professional
OWNER-BUILDER DECLARATION
i4 I hereby affirm dol I am exempt from the Contractor's License Law for the
O O following reason.(Section 7031.5,Business and Profonsiom CmdC:Any city or county
s
99 which mention a pcmlil to mnmrocl,elle,improve,demolish,or repair any structure
Fi< prior m its issuance.also requims the applicant forsuch Permit file a signed smencm -
tat heislicensed punuanttodeprovishomof the Commons License Law(Chapter 9 Sq. Ft. Floor Area ValuatJDB800
¢ss-O (commencing wish Section 7")of Division 3 of she Rustiness,and Professions CmIC)or a /
a $ Nat he u exempt therefrom and the basis for the alleged exemption.Any violation of
Scetion7031.5 by any applicant fon Permit subjects Neapplicanl to a Civil penalty of APN Number Occupancy Type
not mom Nan five hundred della.n!KX)).
01,az Cwncrofrhe propcny,amy employee with wages as deumlc compensatlmn, 35911048 . 00 w
will do the work,and the aWCmR Is not initiated Or Offend rnr SalC(See.70')44,Buslneas /'
and Pmfessioe Code:The Contractor's License law doer ant apply to in owner of Required:In"spections
propsny who builds or improves thereon,and who deesauch work hurnelfor through his b N �/
Own employ=.pmvidcd that such Improvements sec not intended Clattered rte sale.If. (�
however,she thailding or improvement is sold widin om year of eamplouon,she owner
builder will have the burden of proving Nal Ice did not build or improve for purpose Cr `
salt,.. �P
❑hes owner of ct property,.B exclusively and
Prof ding Cod licensed romneton m
Construct Ls it project(Sec.oan Owner
and Professions Code;)i The Contractor's rad
cense Taw does not apply je an owner of pompons who builds Cr improve thereon,and
who cmmuacu for such projects with a contrmtor(s)licensed pursuant in the Conuaetofs
Lken law.
❑1 am
exempt under Sec. .B&P C for this reason
Owner Date ® G
WORKER'S COMPENSATION DECf.ARATI '-
1 hereby aRm runder penalty of perjury one of she following declarations:
' r I have and will maintain a Certificate of Consent self-insure for Worker's Compere
satin,az provided for by Section 5]00 of the labor Codc,for the performance of the
wart for which this permit is issued.
❑1 have and will maintain Worker's Comprourohn Insurance,az required by Section
3700 of the Labor Code,for Ne performance of the work for which this Permit is issued.
My Worker's Compemation Imurance carrier and Policy number sm-
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Old,rection need not bt completed if de cmail is for one hundred dollars(SIM)
or Loss.)
I certify Nat in thc parf.too..of the work for which Nis permit is issued.I shall nut
employ any penin in any manner sa na to become subject o doe Worlems Compeeadon
Law s of Californi
Applies t
NOTICE TO APPLICANT:1,a ser making this Certificate of Exemption,you should
become subject to the Worker's Compewtion previsions of the Labor Code,you most
.,O foMwi lh comply with such provisions or this Permit'hall be decimal revoked:
z CONSTRUCTION LENDING AGENCY
(-+ V` I M1cmhy affirm Nal there is construction lending agency lot the performano of
7 the work for which Nis Permit is issued(Scc.31097,Civ.C.)
W A Lendefs Name
6.
JZ Under's Address
V 0 I tinily that I haus read this application and auto diedces tit about tws relating u
0f bu�n.1agreeto comply with all airyand county ouives critics
slat claws relatingto
e
OU abowngconsuuctito, ryhereby audorinnoses. ive or Nis city to enter upon of
r CL above-(We)agree
to saw.
finInspection indemnify
apm op hat
CL (We)agree to Cost,indemnify and kith harmless the City of Cupertino against
.I"„Z inconsecejudgmtnuecosuang of this emit. may in anyway accmc against said City
C.y z A APPLICANT
of UNDERSTANDS
this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULA/TI�ONS.
Signuun ofwpplicanVConuumr D,too� Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will On applicant or future building Occupant store Cr handle hmardous material
Cs defmcd by Ito Cupenino Municipal Cade.Chapter 9.13,and the Health and Safely
odc.Section 25532(¢)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes QNo
11
Will the applicant or future building Occupant use equipment dcvima which
If a roof is installed without first obtaining an inspection,I agree to remove
it betatrons;air contaminants u defined by the Bay Arta Air Qualority Management all new materials for inspection.
iuric4
C]Yet [DN.
1 have mail the hoardous materials requirememu under Chapter 6.95 of do Califor.
.is Hcald&Safely Code,Sections 25505.35533 and 25534.1 undersand Nat it con,Wilding
der not currently har5 a imarn,111up it is my seepmaibility m nmufy tit occupant of the
requirements w rth m "'r mtl r to issumsce^f a Campmate of Occupancy.
�� ;7G Signature of Applicant Date
Owner or amhmmcd agcm Dale 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
�UPEf�TINO
Building De artment
JOB ADDRESS: PERMIT #OS -0 3 pp S
/G/ 46 —&,C/N /
OWNER'S NAME: v N PHONE #01(-06 . [/y,6 _ Y,(,
GENERAL CONTRACTOR: a,t w gu FAX #
I am not using any subcontractors: ('-7 —3`—tit-(qr
ignature 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
So,
FURNACE/AC
CUPERTINO PERDMIT APPLICATION FORM
APN # -3S—? 6 y0 Date: 3 - —0J--
Building Address:
o/ 6
Owner's Name: J-;,7 ' —��s Phone#:
0-b c/
Contractor: 6 Pix / tea ""� /G s License /f
3.
Contact, Cupertino//� Cuperttiino Business License #:
Building Permit Info:
Bldg Elect Plumb C`7 Mech
Job Description:
i �� e�Ja�iNCd deo 0//Z- � rv��✓iov �r6
Residential Commercial ❑
For Residential Installations:
Attic ❑ Ist floor W 2nd floor❑
Adhere to min set back requirement[]
For Commercial Installations:
Replacement same weight E] Additional weight (structural calcs),❑
Structural Calculations required for new installation El
installation Plannin A royal Re uired ❑
Cost of Project: Type of Construction: Occupancy group:
800
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfrn MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfin 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
Mtn. BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING