03070119 CITY OF CUPERTINOx.xT
BUILDING DIVISION PERMIT t CONTRACTOWINFORMATION
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BUILDING ADDRESS: A & H HEATING PERMIT No.03070119
21 9-7A rI%QrrT.L"TQN RTt
OWNER'S NAME: 770 CHESTNUT ST PERMIT ISSUE DATE
GARY YTTNC,
ONE: (408) 279-0722 SANITARY NO. CONTROL NO.
ARCHITEC17ENGINEER: BUILDING PERMIT INFO
BLOC ELECT PLUMB MECH
LOO LICENSED CONTRACTOR'S DECLARATION , Rt
DSCrIb D
w 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOt1 assn
wiNSeetion] ) fDi-lslon Jof Ne BusinusaM4ofcssinm Csmde.andmYlicense is Lj` UA9417
qz ucenm ce Bn ADD A/C W/ELECTRICA CIRCUIT /t •�L�
Dam Contndm AUG (�
A CHITECT9 DEC 1 N G `c 2003
y I on
crsland
my plans shall M used as public records
D U
u Licensed ProfcaslonaI BUILDING
=•D OWNER-BUILDER DECLARATION 1 UILDI
mI hereby Affirm that I am exempt from use Comnnoes License Law for the s a V7
D o following reason.(Section 7031.5.Business and Profession Code:Any city or county -
3�ry which rcqulru a permit to connrun,alma improve,demolish,m repair any m nt n '
F-ZY prior to its issuance.also requires the applicant for Wch permit tri Me a signed statement
££mm< that WI,licensed pu.usot to the provisions the Contractor.License Law(chapter 9 Sq.Ft. Floor Area Valuation
CFD (Commencingwith Section7y )of Division3nfthe Busincuand ProfessinniCMC)or
$ Net he Ie exempt therefrom and time basic for the alleged exemption.Any vinlat(on of 35620048 . 00
Section 7031.5 by any applicant for a permittubjecu the applicant to a civil penalty of APN Number Occupancy Type
not mon then five hundred della.($500).
❑I.Is owner offt pmperty,or my employee with wages Is Nen in compensation, T�
willdo Newmk,and Ne ancient is not intended m offered forsde(Sec.7044,Business — -ROUGH g CLIODS
and Professions Code:The res demur, rid who law dem not apply lf an anter of 303 - ROUGH WHAN CAL
and Pre who buildsscimproveshereon,endwhodanssuchwank himselforthrough his
own employ=,provided that such improvements tient intended or offered forsale.If. 304 — ROUGH ELECTRICAL
howerco me building or improvement s sold within one year of completion,the owner.
builder will have the burden of Proving that be did not Wed or improve for purpose of 501 - FINAL ELECTRICAL ENERGY
44th')' 502 - FINAL PLUMBING ENERGY
❑h u owner of the Sec.704,.Business udus sad contracting with licensed attract tors m
wmnm Uteespmjcct tapply Tan Owneofpodnywh Wi CMrJTbeves utman.Li. 503 — FINAL MECHANICAL ENERGY
muefawdmanouppytaanoth a ofproperty who sedetnoram toed thereon,and
. 505 - FINAL ELECTRICAL
who contncu fonuch prolecu with a contrunor(0 ticense0 purtumno We ConmmoYt
Uicense Law. 507 - FINAL PLUMBING
0 I sm uempt under Sec. ,B At P C for this moon
508 - FINAL MECHANICAL
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declata0om:
1 have and will maintain•Certificate of Consent to self-insum fm Wmtn's Compcm
13CI.)I',WoffficUborC�,fDr�pcdominccofNew
an,Co provided for by Section 3700 of the Iaber Code,for the performance of the
k for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section
k r which Nis permit m Issued.
Works ovation Imunna camicr end Pali nth ram:
A 1fer G(�t S Policy o.:�'- -
102,047
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
Obis sectitn need not be completed If the permit isfnrone hundreA dollars($100)
or less.)
1 eenify that in the performance of the work for which this permit is Loved.I shell not
employ any person in any manners as m become aubjecua me Workeri Compensation
Laws of Coliform..Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you Mould
become subject he the Worker's Compensation provisions of the Iwbm Cede,you must
,JO forthwith comply with such Mrwisims or this permit,hall be deemed revoked.
zCONSTRUCTI ON LENDING AGENCY
Iherchyaflon Nn Nen Y.cmbuninn lending agency l'nr the performance of
�i me work for which this permit Is issued(Sec.3(97,Civ.C.)
QLender a Name
]z Lender's Addreas
U Q 1 certify that I have read this application and state that the a Wve information is
W F Cmsen.l agree to comply with all city and county Ordinances and tum laws relating to
O U building eonsnnion,and hereby suthorire representatives of this city to enter upon the
a shove-(We)are to save lm inspection purposes.
(s Ju agree to Cove,indemnity and keep may
in an the City ru against s idCtagainst
wF.vh in
f ts,the granting
uind a this permit. may in anyway accrue egainnsaidCity
Uzi in mnuquenec of the gnnling of this per mit. /
P ICANT UNDERSTANDS AN WILL COMPLY WITH ALL NON-POINT Issued by: Date
REGULATIONS.
a✓� Re-roofs
Signature.! pplinnUContnctm Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicem or future Wilding occupant non Or handle ha'rudous material
u defined by dm Cupertino Municipal Co&,Chapter 9.11,and the Health and Safety
Code.Section 155J1(a)1 All roofs shall be inspected prior to any roofing material being installed.
❑Ye Nu
Will the applicant or future Wilding arupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haurdous air contaminants u defined by me Bay Arca Air Quality Management all new materials for inspection.
nrict7'
❑Yes
1 have mad the hanrdnus materials requirements under Chapterti.95 tithe Califor.
nia HcAlm&SafelyCM,Secuum 8505.8533 and 15534.1 uMe.und NAL if dm building
jLimmcnL�
o0y have a one L th t It is my responsihility m nnuly tbe occupant of the
which must he onnissumcc Cenin r u cCftlSignature OfApplicant Date
JZ/ All roof coverings to be Class"B'• or better
homcdage Date
CITY OF CUPERTINO
FURNACE /AC 03 /
UPEKTINO PERMIT APPLICATION FORM k
. APN # 00.�� Date: r�
f'
Building Address:
o?157Lt CAgagtwi sr
Owner's Name: Phone #:
Contractor: License #:
Contractor* 146* N G o c 3p If VA
;. Contact: Phone #:
DL6 PARBS a 79-o7a� i
Applicant/Contractor:
PALC NewcPs
Building Permit Info:
�,-34 BldgElec Plumb Mech
ry. Job Description: yu R l.r
Residential: e — IJ9CO+ a1JFC k,( 't�ommercial:
Sq.Ft. Floor Area: /S .Ft,:$
Architect/Engineer: Valuation: 1 LZ
ype of Construction: Occupancy Groul
f
Qty. i I
' -A 1' a e Fee ID Fee bescri tion Fee Group
BENERGY Energy BUILIDNG
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 i
BSEISMICRE Seismic Fee Res BUILIDNG
' 1
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMI'ITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
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