04060136 ' CITY OF CUPERTINO --
BUILDINc DIVISION . PERMIT CQIVTRACTOR`INFORMATIO,N
BUILDING ADDRF S: CONDITIONED AIR PERMIT N004060136
21884 BYRNE CT
OWNER'S NAME: FER IFTISUE DATE
MARCIA SMITH 1701 LITTLE ORCHARD
NE: SANITARY NO, CONTROL NO.
(408) 291-2220
ARCHITECf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
+,+Oo LICENSED CONTRACTOR'S DECLARATION lobDescri tion
m I hereby affirm that I am limmad under previsions or Chapter 9(commencing P
`+ with tion]agp ser Division Sof NC Busineaswd Prefessiarta Code.and mylicentt ix 2
ren �aCDIXI. �/" REPLACE FURNACE & ADD A/C FUNALSO)
Dq? Liccntt L'e.N
Z'O Da Cum 1
�� ARCHITECI'SD -TIO r)oOrl
Y
dersmnd my plans shall be used m public records JUN d2 L
1yU
an Licensed Professional
5 OWNER-BUILDER DECLARATION A gp��Nl
I hereby afOrm Ihel I am exempt(rum the Conbacmrs license Law for the BmIDI VG'
p o following mason.(Section 703 1.5,Business and Professions Code:Any city or rou..y
x m fi which requires a permit to ennatmn,alter,improve.demolish.or repair any,suucmic $5400
v—'^ prior to its issuance.M.requinn domplicanm for such permit It file a signed statement
��< that he is licensed pursuant to the provisions of the Contractor's Licenx Law(Chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section TIDO)of Division 3 of the Business and Profusions Code)or
y Nat W is exempt therefrom and the basis far the alleged exemption.Any violation of
Section 7031.5 by any applicant for it permit subjects the applicant on a civil penalty of or 0 Occupancy Type
not more Nan five hundred dollen(350)).
p I,vowncrof Ne propony,army cmployceswith wages nihilistic compensation.
will do the work.and the structure is not intended oroRered forage(Sec.7W4,Business
.it Professions Code:The Conuacmn Limnse Law does not apply to an owner of 'Required Inspections
property who builds or improves thereon.and who dean such work himself or"rough his
own employes•provided that such improvements are not inmldeA oraRered far ole.If.
htwcvm.the Wilding or improvement is mid within ane year of compictian,the awncr-
builder will have the Wrdm of proving that he did not Wild or improve for purro ,of
ofte I.
1,as owner of the property,am exclusively contracting with licensed etmraccers to
construct the project(Sec.7064,Business and Professions Code:)The Conuumr's Li
cove law docs not apply as an owner of property who Wilds or improves thereon,and.
who concocts for such projects with a contr.mKs)licensed pursuant m the Com uctoes _
License Law.
❑l am exempt under See ,B&PC for this mason
111�-
ner Data -
WORKER'S COMPENSATION DECLARATION
ir
1 hereby affirm under penally of perjury ane of Ne fallowing doelvatiov:
1 have and will maintain a Certificate of Consent self-inum for Wolates Com it-
on,as provided for by Section 37W of the labor Code,for the performance of the
rk for which this permit is issued.
1 have and will maintain Workers Compensation Insurance.as required by Section
0 of the Labor Code.for the pc uccurce or the work fur which this permit is issued.
Workers Compensation Insurance carrier and Policy nuuym�be'frr Cme: /�
�rTON�$Ie/},"]� S•Pyicywo. ]�SLI
CERTIFICATE0 PFMPnO`A�FR`6 WOORRKERS'
COMPENSATION INSURANCE
(This section need not k completed if the permit is for one hundred dollars(glens)
or less.)
I certify that in Ne performance of the work far which this permit is Wood,I shell not
employ any person in any manner an as to become subject to the WorkersCompensation
Laws of California.Date
Applicant
NC`oCE TO APPLICANT:If,after making this Cenifieam of Exemption,you should
become,subject in the Worker's Compensation provisions of the labor Cook,you must
.JO forthwith comply with such provinces or this permit shall W deemed revoked.
Z '-' CONSTRUCTION LENDING AGENCY
F'= IWreby aMo.laid there is.canslmctim.lending acency Bar the Perform..or
L1'> the work sur whim this permit is issued(Sec.3097.Ci,C.)
W Q Lender's Name
=z Landcr's Addreas
V C) I cm)fy dm 1 have read this application and mute that the above or...dean is
LL P corms I agree to comply with all city and county ordinances and state laws relating in
OU building construction.and hereby aul trim repreumatim or this city to enter upon the
r W above mentioned property for inspection purposes.
(, 4. (We)agree to save,indemnify and keep harmless the City of Cupertino against
N liabilities,judgments.costs and expenses which may in any way accme against void City
U in consequence of the granting of this Permit.
" AQPLICANT UNDERSTANDS AND W COMPLY WITH ALL NON-POINT Issued by: Date
$ RC ULATIONS.
s. / e '� Data 'o Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or furor building occupant store or handle haardaus material
az defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safely
ode.,Ei Y.255yi 7 All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use,Tipmeal or devices whim -If a roof is installed without first obtaining an inspection,I agree to remove
mit havardous air contaminants as dcrined by the Bay Area Air Quality Managcm.l all new materials for inspection.
7taHcxlth&SafiayCodIa.SacWxI
istrict?
❑Yes �Nn
I have mail the bavardous materials requirements under Chapter 6,95 of the Califor-
oma 255X.1 unatmand thvirdv building
rcsmolcurtcndyhalea¢namNatiti my ponsihiirymnotifyolearup.tofNcam which aathcm prior Ire ce.l. ani ateoraafancy. Signature of Applicant Date
G- - 17 All roof coverings to be Class"B"or better
Owner r mumaued¢gem Dec
Community Development
10300 Torre Avenue
aumvCupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
SUPERTINO
Building De artment
JOB ADDRE . PERMIT# OuQ(0Q 3 (�
OWNER'S NAME. Leh d PHONES C4oS) X91 O
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
Signature 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 A%Y-
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
�( 616 ,o41
Owne Contractor Signature Date
CITY OF CUPERTINO o G o
FURNACE/AC
as
CITY OF
CUPERTINO PERMIT APPLICATION FORM
APN # Z Date: _ lie
Building Address:
o2i 694 BW A- Cf—
Owner's me: � phone G O
0-retw O�
ontractor: Ph n : License #:
44, `f 457(op a-C-20
tact Phone: Cu ertino Busin4 License r{
t✓l r 8 a9i -aa3 `a� /
Building'Permit Info:
Bldg ❑ Elect A Plumb ❑ Mech
D scr' tion:
Odd on 4(e--
Residential
eResidential Commercial ❑
For Residential Installations:
Attic ❑ ls` floor ❑ 2nd floor❑
S Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional'weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑ ------A-,
Cost of Pr eet: Type of Construction: Occupancy gro p
K � �)/
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Arel------
New Location ❑ Re lacement ❑
Qt if
A le Fee ID Fee Description Fee Group
ENERGY 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
BSEISMICOM Seismic Commercial BUILIDNG
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 7 / BUILDING
(S / Z