03110089 TINO
lv CITYILDF c mviSSIiON CONTRAG-T0R INFORMATION`y-i
PERMIT{
BUILDING ADDRESS: A & H HEATING PERMIT N003110089
OWNER'S NAME: PERMITISSUEDATE
BORAH EICKLEN 770 11 /18/2003
NE: SANITARY NO. CONTROL NO.
(408) 279-0722
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+00 LICENSED CONTRACTOR'S DECLARATION Job Description
E(y 1 hereby affirm that 1 cooP
nsed under provisions of Chapter 9(commencing
with Seam li
ction law)of Division 3.f the Bari nuv and Professions Code,and my license is
Lida. lass: effect _'1417 Z ADD A/C & 220 VOLT CIRCUIMaI�fi��®
Z in fullt=a tea/ LIc.N �''\
3 Date Contractor r—
e ARCHITECTS DECLARATION
e 1 undemmd my plane shall im used as public records NOV 2 4 2003 .
,'Cr^ Licensed Foremost
wrs OWNER-BUILDER DECLARATION
I lurch,affirm that I am exempt fru.Ne Cmmrac.rs License Law for the BUILDING
u ■y I SIN
02 following reason.(Section 7(31.5.Business and Profustons Code:Any city or county ",/7
$ which requires a permit to construct,alter,improve,demolish,or repair any structure
prion,its iauanm,.Bu raquiru theapplicant for such Permit o fide.signedmtement
s� 0
that he is licensed pursuant to the previsions of the Contractor's License Law(Chapter 9 Sq,Ft.Floor Area Valuation
y
(c romancing with Section 7")of Division 3 or Business and Pmfcasions Code)or
y $ thmat m is exempt therefrom and Nu
e basis far the alleged anptlon.Any vielaunn of
Section 7031.5 by any applicant fon permit subjects Ne applicant to a civil penalty of . 3 a(RN 3Q m8er 0 0 Occupancy Type
not more than five hundred dellen(M).
❑1,u owner of Ne propmy,or my employees with wages u Heir wle compenadon,
will do the work.and ft.tract..is not intended..Thad(orale(Sec.704/,Business
and Professions Code:The Characters License law docs not apply to an owner of Required Inspections
property who build&or improves thereon,and who does such work himself or through his
own employees,provided thatauch improvements art not intended oroRerW(orale.If.
however,Ne building or improvement is sold within one year of eampinan,the owmn
builder will have the burden of proving mal he did not build or Improve for purpose of
rem).
❑1,as mvner of me propeny,am exclusively contracting with licensed romractors to
construct the pmjecl(Sec.lime,Business and Professions Cade:)The C,ntraclaM1 Lt.
cense law does not apply to an owner of property who With;or improves themon,and
who contracts for such projects with a contractor(e)licensed pursuant to the Conuanw's
License La,
0 I are exempt under Sec. ,B&P C for this moon
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby aRrm under penalty of perjury am of the following declarations:
I have and will maintain a Certificate of Consent o sel6snsure for Whitacre Compcn.
Milan,as provided for by Section 37M of the labor Code.for the performance of the
work for which this permit is issued.
hawand will maintain Workers Compenahon Insunntt,as myuimd by Section
W of the labor Code,for me performance of the work for which this permit is issued.
My Worker's�C�ompensadhn In&unntt artier end Policy n`u'mb r art:
Cmier.TKlr� INS. PoRry N.,:Z I ID O
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu rection need not W completed If the Farms,is for one hundmiddollm(SIM)
car tea.)
1 anify that In me performance of me work for which this permit Is issued.1 shall not
employ any Faxon in any tremor so a m become subject to the Workers Compensation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you mould
become subject to the Warker's Compensation provisions of the labor Code,you mut
�Q forthwith comply with such provisions or this Permit W deemed.voked.
Z CONSTRUCTION LENDING AGENCY
I hereby affirm literature in conswninn lending agency I'or the Performance of
^l. thc work for which this permti is issued(Sec.3M.Civ,C.)
S] im Lenders Name
= z Lenders Add.
U C) I anify that I have read this application and sum that the above information la
;-" correct.I agree to comply with all city and county ordinamn and state laws mlating to
building construction,and hereby authorize upresenutives of this city to enter upon me
G ahovomentioned pmpcny for inspccdon purposes.
(We)agree to Cosa,indemnify end keep hay in my
City,f Cupertino against
liabllid(We)judgments.1.sCos"w,indexpenses oilkee heyinay my me
of C.einstea against
I (Tb
f,Jz inconsequence of the gramir,of this Fermit.
ti APPLICANT UNDERSTANDS AND LL COMPLY WITH ALL N NPOINT Issued by: Date
SOURCE ULAnONS.
Re-roofs
Sign Iureof Appream'Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or future building occupanta.re or handle haraNuus material
o de0ncd by the Cupenino Municipal Code,Chapter 9.12,end the Health and Safety
ode.Sayan 25532(.)7 All roofs shall be inspected prior to an roofing material beim
pr& 39, P P Y g being installed.
Will the applicant or btund building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
7niA
rictl ���/
oYu Larch"
1 have mad the Ward,_...Wrists requirements under Chapter 695 of the Califon
Health&Safety Cade,Sections 25505.25533 and 25534.1 understad that ifthe Wilding
o not currently have a tenant.mat h u my responsibility m madly the m nouns of the
uirc enuwhichmustWmet nriuuaccofaCcniOcate
oil.eney Signature of Applicant Date
Owner or authorized agent V Data - All roof coverings to be Class"B"or better
CITY OF CUPERTINO
FURNACE /AC
CUPEkTINO PERMIT APPLICATION FORM
APN # � 3 o s a Date:
Building Address: Z
Owner's Name: t x Phone ' C 69 6�F79
1!i 3�+ r
Contractor:A4 �. �� License #:Ld-1 � � —
Contact: Eqg�MLE R ` K hone ��-O7a �
Appl icant/Contractor:
4
Building Permit Info:
Bldg Plumb
Job Description-./ A 1 !9 L / ^�
Residentia — Iv Commei at
Sq.Ft. Floor Area: $/Sq,Ft.:
Architect/Engineer: Valuation:( ®�
Type of Construction: OccupancyGroup:
Qt
A tic e Fee ID Fee Description Fee Group
B ENERG Y EnergyB U[L Q?N
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm r MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUMLIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance j -MECHANICAL
PPERMITFEE P16mbing Permit Issue PLUNIBING
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License B FU LIDNG
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