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. CITY OFCUP ERTINO
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BUILDING DIVISION PERMIT
CTQR I1Vtj'U,RMA.0
BUILDING ADDRESS:
DAHL PLUMBING CO, JOHN F
PERMIT N0.
03120045
OWNER'S NAME:
PERMIT ISSUE DATE
O N
SANITARY OL NO.
ARCHIIELTIENGINEER;
BUILDING PERMIT INFO
BLDGO ELECT PO
O
zp LICENSED CONTRACTORS DECLARATION
lob Description
I hereby affirm Lim 1 am humand under provisions of Chapter 9 (eumammin{
with Salla 70118) of Division 3 of the Buaon+t� Profenmns Cade. and my liee.b
full Co. In
mf"Bf"R�`D �
REPLACE FURNACE (35000 K BTU)
z Li Lr.
Dem Contra
'
ARCH DECF4XXnO
l u to m yApa11 be ati as pts Tic raprd�7
Licensed
OWNER-BUILDER DECLARATION
5e 1 hereby Llano farm
(Rrm Net I em exempt from the Cssion
o city o
O which re mnom (Eagan 703 L]. B"slan, and are, derUN Code: Any Lm ar shanty
. y
wham a permit m muss aim= Improve, ri repair any structure
id, inu tri h rzmith,
�a Pdwmiu iasuanee.e[au require theapplmanf fm Snch Permit reran
'Sq. Ft. Floor Area
Valuato
eLaedmmmcnt
c that he is licensedpwnnnuameProviaioNolthaConuacror'sLImNeLew(ChaPmr9
(commercial with Section 7800)of Division 3 ofdon gourma nd ProfwuoN Code)m
that he [a awnp, menfrom and the basis for me alleged exemption. Any violation of
3'f P 170 0
Occupancy Type
Section 7031.5 by "applicant foo a permit subjects the Applicant o a civil penalty of
act mats than Rw hundred do1Wa (M).
01,ue ofthepmpmy.wmymoploycewithwagumthetrmletampenndon,
Required Inspections
will dmhe"AlL and she turcutm ismaim nded wa@Ted fonde(Sm.7014. Bonuses,
and Plainsman; Code: The Contractors License Law does ant apply m an owner or
9 P
property who Wildsw Improv thereon, and whodanslushwarthi uldfw though ma
awn employea, provided thatmeh Improvemanss am nutimmnded mustered forum. if.
however, the building car improwmem [amid within ore year of mo plado", she .,-
Wild., wi0 have the burden of proving that he did ant Mid w Mailman for purport of
FI ISI A 1+ED
asle). .
nuon m
❑ I, As owner of the property, am exclusively contracting with licensed men
contract the project (Sac. 7044. Business and PmfNaiaN Code:) The Cartago Ll-
improves dmmem,
DEC 1 2 2003
ante Law does not apply m an owner of property who builds or and
who anm mis for such pmjcm with amnumnw(s) licensed purmam An the Cantramah
License Law.
- ..
❑lam aemPt undo Sec. ,B&PCforthis Towson
BUILDING' '
Owner 'Dam
WORKERS COMPENSATION DECLARATION
1 hereby affirm under peNlty of perjury arc of me following dastaradOw
m of Consent self-Insure far Workee,Compen-
1 have and will maintain a CertiBacem
a ties. u provided far by Harlon 3700 of the {AW, Cade, for the performance of the
wool, for which this permit Is issued.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code. far the performance of me work foo which this permit is mound.
My Worker's ')CampGN� d /Illnlmnm CBnIat and Policy number am'
c 'erljjw Policy �Nop le,5�99�L
CE FICATEO %EMPnOryyrO's WORKERS'
COMPENSATION IN5g0ORANCH
(Thhsectlm reed natbscumplemd date permit is foram hundred dollen ({100)
On INF)
1 certify that In the pullormanm of the wart for which this permit is Issued, I shall not
employ any person In my manner an u to become orbital to she Worked Compensation
'
Laws of C.1ifomis Dam
'
Applicant
NOTICE TO APPLICANT. If, after making this Certiflam of Exemption. you mouth
ism arm subject to the Workers Compmumm provisions of me Labor Cade, you muss
'.Z forthwith comply with such provision w this Permit mail be dared revoked.
0
y CONSTRUCTION LENDING AGENCY
1 hereby a1Rrm out men Is a coNuuctinn rending agency far the perfwmamc of
i the work for which this permit Is island (Scor 3097. Civ. C.)
QLanders Name
Lenders Address
QI cenify that I haw mad this applanation and mm mu the above Infomatiun L
contact l Mme to comply wish all city and county ordinances and mm laws relating to
building coNuncmn, and hereby aumouae mirmsenutiwa of thiscity m emus upon mo
above-mendoned pMPerty for inspection Purposes
f
nl
(We) agree m saw. indemnify and kap harmless she City of Cupertino against
IA llabilide, judgmanss. mass and expenses which may in my way accuse agdNtadd City
'
in consequence of the Starting of this Permit.
APPLICANT UNDERSTANDS AND WILLj COMPLY WITH ALL NON-POINT
Issued by: Date
souRCk.gPrrn .nGN 03
Re-roofs
Type of Roof
{nature ofAirplicantlContractorData
H AZARDOUS MATERIALS DISCLO
Will the applicant or future building wcupanutem or handle hazardous material
as defined by the Cupertino Municipal Cale. Chapmr 9.12. and the Health and Safety
Code. Section 25532(87
All roofs shall be inspected prior to any roofing material being installed.
❑Yes -&No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant ux equipment or device which
mit lm ar nus air con uninanss a deflned by ma Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes ,H No
/\
I have mW the meardous materials requirements under Chapter 6.93 of the Califon.
nixHN10&safctyCde,Sadom75505.25533ud25534.lunrkword a ft Wilding
does not eminently haw a mr am, mat It 4 my responsibility An rusty path of me
requuem M ntbe t.Pdor, Aanaa mill too ey.
Signature of Applicant Date
0 y - 11- 03
All roof coverings to be Class "B" or better
-
Owner or w horimd agent Dam
CITY OF
CUPEIZTINO
CITY OF CUPERTINO
FURNACE/AC /
PERMIT APPLICATION FORM
APN #
Date:
Building Address:
BREMFURN
a 3 iS
MECHANICAL
Owner's Name: /
I
op #:
em �ZS _
Contractor: Phone:
o"1 G o ! -C/ -x-20
License #:
Contact: Phone:
Cupertino Business License #:
BREMRECEPT
SS
Building Permit'Info:
BSEISMICRE
Bldg ❑ Elect ❑ Plumb ❑
Mech
Job Description:
�3S CAk,�
Elec Permit Issuance
ELECTRICAL
MPERMITFEE
Residential '®" Commercial ❑
MECHANICAL
For Rggidential I llations:
Plumbing Permit Issue
Attic u I" floor& 2nd floor ❑
BPERMFEE
Adhere to min set back requirement [I
BUILDING
For Commercial Installations:
Plan Check Fee
Replacement same weight ❑ Additional weight (structural calcs) ❑
BUSLIC
Structural Calculations required for new installation ❑
BUILDING
New installation Planning Approval Required
Cost f Project: Type of Construction:
Occupancy gr up:
5b,Ov
Strapped ❑ On Platform Bonded ❑
Sq.Ft. Floor Area:
New Location ❑ Replacement's
Ann]' n 1A
FrP TT)
F", Da.vrrintion
Fee Group
BENERGY
Energy
BUILDING
BREMFURN
Relocation of Furnace
MECHANICAL
BREMACOVER
A/C Unit > 10,000 cfm
MECHANICAL
BREMAIRHAN
A/C Units r- 10, 000 cfm
MECHANICAL
BREMRECEPT
Rec tl, Switch & Outlets
ELECTRICAL
BSEISMICRE
Seismic Fee Res
BUILDING
EPERA11=
Elec Permit Issuance
ELECTRICAL
MPERMITFEE
Mech Permit Issuance
MECHANICAL
PPERM=E
Plumbing Permit Issue
PLUMBING
BPERMFEE
Bldg Permit Fees
BUILDING
BPLANCHK
Plan Check Fee
BUILDING
BUSLIC
Business License
BUILDING