03120003 FCITY OF CUPERTINO ' s-
BUILDING DIVISION PERMIT CQNTRACTQRIINFORMATION
a r .
LU NG ADDRESS: PERMIT NO.03120003
9955 BRENDA CT
'ERS NAME: PERMIT ISSUE DATE
aDAR SHACHAE 12/01/2003
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECr PLUMB MECH
= 0 0
i00 LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am lianxd under provisions of Chapter 9(commencing Job Description
wiNkction101117)of Divialon3or Oe Businm`u�ofcssimsCodc.andirylicanseis
+ in lull foae o fee _ D 3 V (� [ O d' 7 FURNACE
j q Z Lica¢ In k.s
Da¢ 2 Contractor
rq ARCHITECTS 01ON f
4 a smnd my plana shall M mud a .To,Js
56
.0� it
Licensed Pnsfcsional
3 OWNER-BUILDER DECLARATION
0 1 hereby.('firm Not I.m exempt from the COalrns Co e:Any
Law for the
p O rollawinguina a.(Section](131.5,Business
t.ai err. andimp,ve de um Coda:Any city or county
S$ which)itsisunpermitmeans the pipeimprov,h Permith.me a sig any Samoan 0
i y that he its issuance,p also RyoIfre pmvisi applicant for such Permit Lice l,Law statement l -
2 G IhaiheislicgwithSnuontmNepmviviomnfNcCousireaandProflaw(Chad.) Sq.Ft. Floor Area Valuation
Z � that het,exempthim.foonand7 of Division3Ofthe Busineu.nd Professions Calc)or
x, Net he H exempt Nemfrom and On bnu for Ne alleged cumpslon.Any vinlatlon of
Section 7031,5 by arty applicant for a permit ubjmu the applicant to a civil penalty ofNUFa Occupancy Type
not more Nan five Warred delta.(M).
00 P Y YP
❑I,u owner of the property,or my employees with wages as Meir vele compensation,
will do the work,and On structure is not intended or Offered for selc(Sec.7044,Business
and Pmfeulons Code:The Convector's Liana Law does not apply to an owner of Required Inspections
proartywh0binha rbeamnsthe...... who doese=hwork himulfm Nrou'gfi hit+ — _.
own employers,provided that such improvements au not intended m offered infinite.U.
howwr,Ne building or improvement lased within one year ofcompletion.Bali owner.
builder will have Ne burden of proving Nn he did not build or improve for py[rp.0 of
sale.). ff-
❑1,as owner of the property,am exclusively contracting with liecnud contactmalo
coutrua the project(Sec.7Od4,Business and Profesaiem Code:)The Conloci LP. 'p
came law does not apply to an owner of property who builds o,improves ylU
who contracts for such projects with o enntracLor(s)licensed pursuant to Ne Contractor's
License Law.
1 am exam pt under Sec. .B k P C for this moon
r Dat
WORKER'S COMPENSATION DECLARATION
I hereby aRimt under penalty of perjury oro of on following declarations:
I haw and will maintain a CerdBnm of Cement 0 self-imam for Warmer CMPcm
nation,as provided for by Section 3700 of the Labor Code,for Ne performance of the
work for which this permit is issued.
1 ban and will maintain Worker's Compensation Insurance,as rtq.inad by Section
3700 of Ne labor Code,for dp performance of the work for which this Permit is issued.
My Wmknek pamation TO.. c carrier and Policy number art:
iMPolicy
RTOFEXEf10N WORKERS' S1�7b
COMPENSATION INSURANCE
MlOsection mad notM completed if Me Permit Is fare=hundred dollars DLCO)
it,k".)
I certify thin in the performance of the work for which this Permit is issued.1 shall not
employ any person in any mannerao as m become subject to the Workers'Compemation
Lawsof Cafifomia.Data
Applicant
NOTICE TO APPLICANT:If.after making this Ceniflmha of Exemption,you Mould
become subject to the Workers Compensation provisions of the labor GMs,you must
QO forthwith comply with such provisions or this Permit 4 deemed ranked,
Z M CONSTRUCTION LENDING AGENCY
I hereby aff on that then is a convection Pending agency for the perfmmana of
thc work for which this permit Is i.ucd(Sec.3(59],Civ.C.)
S.1 Q Lender's Name
= z Iander's Addreox
U Q 1 certify that I haw reed this application and state Nu Ne Mon information is
Y. F correct.I agme to comply with all city and county ordinances and state laws plating to
QU building c..anchon,end hereby anthoriureprumoatins of Nis city to cote,upon the
r ahovomentioncd property far inspection purposes.
(„� C (W agree to saw,indemnify and keep harmlaat the City of Cupertino against A
y
ii hill .jar mcnu.AS,7r
apcs which may in any way acrnp against aid City
U A PLIC ucn e f (his ANWILL COMPLY WITH ALL NON-POINT Issued by: DateS URCE AT
Re-roofs
!oRature of ApplivaVContrumr Dap
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Of future building occupant store or handle havardous matenal
defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
.L,Y.25532(x)1 � All roofs shall be inspected prior to any roofing material being installed.
❑Yu
Will the applicant nr Tatum builJing occupant esu eyuipmcnl orJcvias which If a roof is installed without first obtaining an inspection,I agree to remove
h horaNnua air contaminants in de;figed by Ban Bay Arca Air Quality Management all new materials for inspection.
isvic@
❑Yes u
a madNc of Nnusmakrialsp uimmenuunder Chapter6.95oflhe Califon
niaH.1 cry, ,Sc x25505 33 and 25534.1 understand onto ifthc hailding
d.0 not. sly n th u my respomihility m amily the=cap.(of the
.p wh m sa ,tui .a=aancenificanorfxa . Signature of Applicant Date
Owner or awhurirnd agent Date 0 All roof coverings to be Class "B" or better
CITY OF CUPERTINO
FURNACE/AC
alo r
#CUPERTINO PERMIT APPLICATION FORM 031020003
APN# r' Date: �Z /0 3
Building Address:
ss
Owner's Name: hone#:
Contractor, 'Phone: p // / License #:
.5-67,,6 7 6 O�
Contact: Phone: Cupertino Business License #:
/y11,-6 o a�3-S6 6
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description:
Residential �. Commercial ❑
For Residential Installations:
Attic ❑ 151 floor k2"d floor❑
Adhere to nein set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planmug Approval Re uired ❑
Cost of iect: U Type of Construction: Occupancy group:
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Re lacement�`1
Qty. .
Appljt4ble Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfin 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
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbin Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING