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04090253CITY OF CUPERTINO r€^ PERMIT. CONTRACTWINFORMATION • - BUILDING DIVISION , BUILDINGADDRESS: 0500 CARTTNR AIT A PERFECT CLIMATE PERMITND04090253 OWNER'S NAME: PERMIT ISSUE DATE SHEILA VASANT ONE: SANITARY NO. CONTROL NO. 408 861- ARCHITECrIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH ION LICENSEDCONTRACTOR S DECLARATION IC ONTRA Job Description n under provisions of 9 (commencing 1 thereby affirm Nat I am under non I am D with Sccuon 7") of Division 3 of the Business and Professions Code, rW yliccoseu ( �-=� in full f cfftta Licensee.. 2 S se REPLACE FURNACE & ADD A/C OCT l 1004 Talc ConDECL • �� ARCHf1ECTS ECLARA ION 1..L; nJ my plans mall W uScd a public records D D p Iw r, Licensed profehen,h, OWNER-BUILDER DECLARATION ir,, exempt from the Contractor's Law for the 1 hcrchy affirm Nat 1 I1ulfk�\\\Ilfl' l/`/vw U D e: Any c following ¢tion. 703 1. Business and Pmfessimu Code: Any city or county IIIIIS emit t str a alar. improve. h, art sig which requires a permit to Construct, tor'Schustatement prior m its issuance, also rt t h Permit e a ed th. the applicant for such permit m Ne a signed stammcm Ft. Floor Area Valuation to that he wit pursuant to N) pm visions of theContractor's Sq. (commencing 3of usinomnd Professions Code) or (commencing of with Section7")and exempt Professions Damon radon Nat W u eaemps therefrom and Ne baso for tW alleged exemption. Any violation of interthe sho al eged 3 2VP$I2P0uacr0 0 Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of .or mote than Ove hundred dollars (5300). 0 1, m awner of the property, or my employees with wages as Heir sole compensation, Required Inspections will do the work. and the.numure is nut mtmdcd m offered formle (So,. 7041, Business and Professions Cock: The Co mentri Liana Law docs not apply to an owner of propertywha WiSlam improve thereon, and wh.d..,.h work himselforNmugh his own cmployeo, provided Out such improvements are natin¢nded or oRertA formic. If. however, Ne building or improvement is Sold within ouc year of completion. Ne owncr- build,r will have the burden of proving Nat W did not Wild or improve for purpose of sake.). 0 1, as owner of the property, am molusively countering with licensed comm W tars to construct the pmjttt (Sec. 7014, Business and Professions Code:) The Contractors Li- cots, law dors not apply to an owner of property who Wilds or impmwa thereon, and who contras for such pmjecs with a conuector(s) licensed pursuant to the Conuactor's License law. 0 1 em exempt under Sec. B At P C for this rtamn Owner Dale WORKER'S COMPENSATION DECLARATION 1 hereby affirm under pera ty of perjury one of Ne following declarations: I ham and will maintain a Centuries¢ of Consent to self-insum for Worker'sCompen- sation, as provided for by Section 3700 of the Labor Code. far the performance of the work for which this permit is issued. [3,1 have and will maintain Worker Compcmation Insurance, as required by Secuon ,3700 of th, Labor Cade. for the performance of Ne work for which Nu permit is issued. MyWorker's Camp9 myon ismiance artier and PolicymWr are: Carrier: No.: '',,I�,,,�JJPP..,,licy CERTIFlCATE OF EXEmr�tON FROM 'YORKERS' COMPENSAIlTTl1110000NNNN INSURANCES/ ' (This account need not W eamPleted ifft permit is 1,61anc hundred dollars ($100) in less.) I Certify Na in the porfor mane of the work for which this permit is issucd, l shall not employ any perun In any manner an as as became subject to the Workers' Compenuuon Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this CcNOcare of Eacmpsion, you should become subject to Ne Worker Compensation provisions of the Labor Code, you must foodwith comply with Such provisions or this permit shall W deemed r^mked. ) CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the ponformancc of ' to work for which this Nonni, is issued (See 3091, Ci, C.) Lender's Name Lerames Address j 1 comfy that 1 have read this application and soon that Ne above information is correct. 1 agree to comply with all city and county ordinances and sure laws relating to building construction, and hereby authorin representatives of this city to enter upon the I above-mentioned pmpefty for inspccuon purposes. (We).gra to save, indemnify and keep harmless he City of Cupertino against j liabilities,judgments, costs and expenses which may in any way acc= against mid City in consequent of the granting of this S permit, WITH ALLLLyNON-POIM ' APPLICAAN/TSUUNDDDERRSpT.AANDDSS AND WILL COMPLY WITH Issued by: Date SOUR`. //, Re-roofs //(/ Type Of Roof / ///T.(%C/� Imo'/tee/A_ 1 Signaturdof XpipidiantlCorturactor HAZARDOUS MATERIALS DISCLOSURE Will dm applicant or future building Occupant stem or handle h moJous material as &food by Use Cupertino Municipal Code. Chapter 9.12. and the Health and Safety code. we.25532O)7 All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove - Will the appliantrr fur mrt building occupant use equipment or devices which mit haiardno air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection. DitricR 0 Yes I have read dre hav nusmamrials requimmcnts un&, Chapur 6.95 of Nc Cattle, ria HalN&Selesy Code. Sections 755(15.25533 ame 25534.1 understand Nat if the Wilding Joos not curtently haw a mount, that it is my mspomiM1ility m nnNy the occupant of the tcgeiremen astWmmpoortoIssuance ofaCmufaeofOce e. Signature ofApplicant Dale All roof coverings to be Class "B" or better Owner rauthamcJagcm Dare I am not using any subcontractors: _ - Signature Date I Please check applicable subcontractors and complete the following information: f r Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical MA JkT 7 11 �? 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 f r Date f L te l' (u C: . CITY OF "UPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM a�-L,q ° 2-�� APN # , O _ o�j� Date: qL Building Address: V CCN 17W Relocation of Furnace Owner's Name:61he �� ( � 1 Phone #: "L U Contractor:Phone: Vb Vb License #: Contact: Phone: Cupertino Business License #: Building Permit Info: Rec tl, Switch R Outlets Bldg ❑ Elect 0� Plumb ❑ Mec `E Job llescription:, BUILDING Wld, Seismic Commercial �C Residential dY Commercial ❑ Elec Permit Issuance For Residential Installations: MPERMITFEE Attic ❑ I" floor ❑ 2nd floor ❑ MECHANICAL Adhere to min setback requirement ❑ Plumbing Permit Issue or Commercial Installations: BPERMFEE eplacement same weight ❑ Additional weight (structural calcs) ❑ BUILDING Structural Calculations required for new installation ❑ Plan Check Fee New installation Planning Approval Required ❑ BUSLIC Cost of Project: Type of Construction:I ! V Occupa y TAP Strapped El On Platform ❑ Bonded ElSq.Ft. Flo New Location ❑ Replacement ❑ Qty. if Applicable Fee ID Fee Description Fee Group BENERGY 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 R 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 Pen -nit Fees BUILDING BPLANCHK Plan Check Fee BUILDING BUSLIC Business License 4V4,DfNG